AACR celebrates 50 years of tobacco research and policy.

Clinical Cancer Research

Special Report

AACR Celebrates 50 Years of Tobacco Research and Policy Roy S. Herbst, Jennifer A. Hobin, and Ellen R. Gritz; Writing Committee for the AACR Subcommittee on Tobacco and Cancer

This year marks the 50th anniversary of the 1964 Surgeon General’s Report on Smoking and Health. This landmark publication found a definitive, causal link between smoking and lung cancer in men, and, along with the subsequent reports, spurred a series of important public health initiatives that have stemmed the tide of tobacco-related death and disease in the United States. When Surgeon General Luther Terry issued his report in 1964, 42% of American adults smoked; now that statistic stands at 18% (1). The Health Consequences of Smoking—50 Years of Progress (1), the latest report of the Surgeon General, chronicles this decline and highlights the accumulating body of scientific evidence demonstrating the deleterious health effects of tobacco use and the implementation of effective tobacco control policies (Fig. 1). The American Association for Cancer Research (AACR) is proud to have played a role in building this evidence base. Since 1964, AACR journals have published over 2,000 primary research and review articles relevant to understanding the impact of tobacco on health, spanning the continuum from basic to population science. Over the past 50 years, research has dramatically increased our understanding of the relationship between tobacco and cancer, providing a much richer understanding of the mechanisms by which cigarette smoke causes lung cancer and illuminating the links between tobacco use and other cancers. The 2014 Surgeon General’s Report (1) adds liver and colorectal cancers to the long list of cancers caused by smoking and further concludes that the risk to smokers of developing adenocarcinoma of the lung has increased as a result of changes to the design and composition of cigarettes. The report also finds that smoking causes a long list of other diseases, including diabetes, macular degeneration, and rheumatoid arthritis, and that exposure to secondhand smoke causes stroke (Fig. 2). Finally, the 2014 Surgeon General’s Report is the first to evaluate the effect of smoking on outcomes for patients with a chronic disease and concludes that smoking by patients with cancer and survivors Authors' Affiliations: AACR Office of Science Policy and Government Affairs, Washington, District of Columbia This article is being published as part of the AACR's commemoration of the 50th Anniversary of the Surgeon General's Report on Smoking and Health. You are encouraged to visit http://www.aacr.org/surgeongeneral for information on additional AACR publications and activities related to the recognition of this important anniversary. Corresponding Author: AACR Office of Science Policy and Government Affairs, 1425 K Street NW, Suite 250, Washington, DC 20005. Phone: 202898-6499; Fax: 202-898-0966; E-mail: [email protected] doi: 10.1158/1078-0432.CCR-14-0427 Ó2014 American Association for Cancer Research.

www.aacrjournals.org

causes increased overall and cancer-specific mortality as well as increased risk of a second primary cancer. Fostering tobacco and cancer research Research is not only important for demonstrating the multitude of harms caused by smoking, but it is also central to efforts to end the tobacco epidemic, which is why research was at the heart of Tobacco and Cancer: An American Association for Cancer Research Policy Statement (2). Developed by the AACR’s Tobacco and Cancer Subcommittee in 2010, this comprehensive statement urged immediate action to reduce tobacco use and called on AACR members and the scientific community at large to address the tobacco problem through research. The AACR is pleased to commemorate the 50th anniversary of the Surgeon General’s Report on Smoking and Health with a special publication that includes a collection of original, peer-reviewed research and review articles on tobacco and cancer (Table 1). These articles address a range of key topics in cancer control, including the molecular mechanisms of tobacco carcinogenesis (3–6); advances in the diagnosis and treatment of lung cancer (7); new approaches for the use of urinary biomarkers to prevent lung cancer (8); the importance of addressing tobacco use by patients with cancer (9); and the impact of different message framing strategies to promote tobacco cessation (10). Cummings and colleagues (11) provide a historical perspective on the changing public image of smoking. Glantz and Johnson (12) posit that the evidence-based decision-making process used in the Surgeon General’s reports for concluding a causal relationship between tobacco use and disease—breast cancer in particular—has become increasingly cautious, thereby preventing women from appreciating the risks that smoking and secondhand smoke pose for developing breast cancer. Together, these reports add to the broad reach of important tobacco-related topics on the forefront of cancer research and policy. The AACR’s special feature also includes a commentary by Howard Koh, MD, MPH, Assistant Secretary for Health for the U.S. Department of Health and Human Services (13); Q&As with Dr. Koh (14) and Mitchell Zeller, JD, Director of the U.S. Food and Drug Administration (FDA) Center for Tobacco Products (CTP; ref. 15); and news articles on the 2014 Surgeon General’s Report (16) and the science of smoking and cessation (17). In addition to providing avenues for the sharing and dissemination of tobacco-related research, the AACR has specifically advocated for research in key areas. One priority has been to better understand tobacco use by patients with cancer, including its impact on treatment and outcomes. To facilitate research in this area, the AACR has called for the

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Herbst et al.

1964 Surgeon General’s report on smoking and health

5,000

Per capita number of cigarettes smoked per year

Broadcast ad ban

4,000

Synar Amendment enacted U.S. entry into WWII

Nonsmokers’ rights movement begins

Nicotine medications available over-the-counter

3,000

Master Settlement Agreement

Federal cigarette tax doubles

Confluence of evidence linking smoking and cancer

Family Smoking Prevention and Tabacco Control Act

1986 Surgeon General’s report on secondhand smoke

2,000

Fairness doctrine messages on broadcast media

Cigarette price drop

U.S. entry into WWI

FDA proposed rule

1,000

2006 Surgeon General’s report on secondhand smoke (an update)

Great Depression begins

Federal $0.62 tax increase

10 20 12

20

00 20

90 19

80 19

70

19

19

60

50 19

40 19

30 19

20 19

10 19

19

00

0

Year

Figure 1. Adult per capita cigarette consumption and major smoking and health events, United States, 1900 to 2012. Source: 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.

universal assessment and documentation of tobacco use as a standard of quality cancer care in all treatment settings, as well as in cancer clinical trials, and for the development of reliable, valid, and standard measures of tobacco use (18). The National Cancer Institute (NCI)–AACR Cancer Patient Tobacco Use Assessment Task Force, a group composed of academic and federal cancer researchers, was convened to develop recommendations for moving the community forward in this important area, including identification of research priorities and development of assessment measures and strategies. Assessing tobacco use in clinical settings not only facilitates research, but it also is key to identifying individuals in need of cessation therapy (9, 18). The AACR has advocated for the integration of tobacco use assessment and intervention into the training of primary and specialty care providers and encouraged cancer centers to offer comprehensive, evidence-based cessation services for their patients and family members (2). The AACR has also championed the inclusion of tobacco assessment and cessation measures into electronic medical records, the review criteria used by health care quality and accreditation bodies, and into clinical treatment guidelines. The AACR is pleased that the Affordable Care Act (19) includes provisions to expand access to smoking cessation services. Moreover, the 20%

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Clin Cancer Res; 20(7) April 1, 2014

reduction in lung cancer mortality achieved in the National Lung Screening Trial (20) points to the opportunity to provide evidence-based cessation treatment to current smokers who undergo screening and to provide relapse prevention support to recent quitters. In addition to calling on the research community to conduct research that will aid in ending the tobacco epidemic, the AACR’s 2010 Tobacco and Cancer policy statement urged federal policy makers to "increase the investment in tobacco-related research, commensurate with the enormous toll that tobacco use takes on human health" (2). The NIH currently spends about $350 million per year in tobacco research and, along with other federal agencies, has long supported tobacco research as part of its mission (21). The past decade of federal funding cuts, coupled with the impact of sequestration, has, however, had a negative impact on our nation’s ability to fund scientific research and implement effective tobacco control measures. The passage of the 2009 Family Smoking Prevention and Tobacco Control Act (TCA; ref. 22), however, granted the FDA authority to regulate the manufacture, distribution, and marketing of tobacco products and enabled the FDA to provide funding for regulatory science to inform tobacco regulation. Using its authority under the law, the FDA formed an interagency partnership with the NIH through which the



AACR Celebrates 50 Years of Tobacco Research and Policy

Cancers

Chronic diseases Stroke Blindness, cataracts,age-related macular degeneration Congenital defects–maternal smoking: orofacial clefts

Oropharynx

Periodontitis

Larynx

Aortic aneurysm, early abdominal aortic atherosclerosis in young adults

Esophagus

Coronary heart disease Pneumonia Trachea, bronchus, and lung Acute myeloid leukemia

Atherosclerotic peripheral vascular disease Chronic obstructive pulmonary disease,tuberculosis, asthma, and other respiratory effects

Stomach Liver Pancreas Kidney and ureter

Diabetes Reproductive effects in women (including reduced fertility) Hip fractures

Cervix Bladder

Ectopic pregnancy Male sexual function–erectile dysfunction

Colorectal

Rheumatoid arthritis Immune function Overall diminished health

Figure 2. The health consequences causally linked to smoking. The conditions in red are new diseases that have been causally linked to smoking in the 2014 Surgeon General's Report. Source: 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.

agencies are collaborating to foster research that will help the FDA in the development of an evidence-based regulatory framework for tobacco products. Research funded through this partnership will include work on tobacco product addictiveness, toxicity, and appeal; on consumer perceptions and behavior; and on effective communication. One of the first research efforts initiated through this partnership was the Population Assessment of Tobacco and Health (PATH) Study (23). Launched in 2011, this national, longitudinal study of approximately 59,000 Americans will assess the behavioral, social, and health impacts of tobacco product use in the United States. The agencies also established the Tobacco Centers of Regulatory Science (TCORS; ref. 24) program through which the FDA and NIH awarded $53 million to 14 centers to support tobacco regulatory research and train the next generation of tobacco regulatory scientists in fiscal year 2013, the first funding year. The research that is supported by TCORS is focused on examining the adverse health consequences of smoking; assessing the diversity of tobacco products; reducing addiction,


toxicity, and carcinogenicity; and examining economic and policy issues related to tobacco use. Funding for the TCORS program is expected to total more than $273 million over the next 5 years. Promoting evidence-based tobacco control The AACR strongly supports using the knowledge gained through these and other research programs to implement comprehensive, evidence-based tobacco control programs. Recognizing that there is no safe form of tobacco use, the AACR has championed research initiatives aimed at identifying the health effects of tobacco use, as well as tobacco control measures (Table 2). The AACR has advocated for FDA regulation of all tobacco products, including those not explicitly regulated under the TCA, and has taken a strong stance against efforts to exempt cigars from FDA regulatory authority (25). The AACR has also advocated for the establishment of tobacco product standards; restrictions on the advertising, sale, and marketing of tobacco products; bans on products aimed at addicting children; and taxation and


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1712 E.R. Gritz, B.A. Toll, and G.W. Warren (2014)

Tobacco Use in the Oncology Setting: Advancing Clinical Practice and Research The Changing Public Image of Smoking in the United States: 1964–2014 The Surgeon General Report on Smoking and Health 50 Years Later: Breast Cancer and the Cost of Increasing Caution "Quitting Smoking Will Benefit Your Health": The Evolution of Clinician Messaging to Encourage Tobacco Cessation It Shouldn't Take Another 50 Years: Accelerating Momentum to End the Tobacco Epidemic AACR Celebrates 50 Years of Tobacco Research and Policy Urinary Tobacco Smoke-Constituent Biomarkers for Assessing Risk of Lung Cancer Fifty Years of Tobacco Carcinogenesis Research: From Mechanisms to Early Detection and Prevention of Lung Cancer Smoking, p53 Mutation, and Lung Cancer Nicotine-Mediated Cell Proliferation and Tumor Progression in Smoking-Related Cancers Smoking Out Reproductive Hormone Actions in Lung Cancer Advances in the Diagnosis and Treatment of Non–Small Cell Lung Cancer Q&A: Mitchell Zeller on the FDA and Tobacco (includes sidebar on e-cigarettes) The Science of Tobacco Addiction and Cessation (includes sidebar on nicotine vaccine) Q&A: Howard Koh on Smoking Cessation and Policy Report Links Smoking to Poor Cancer Outcomes

Clin Cancer Res; 20(7) April 1, 2014 Clinical Cancer Research, 20(7):1719–20 Clinical Cancer Research, 20(7):1709–18

Cancer Prevention Research, 7(1):1–8

Molecular Cancer Research, 12(1):3–13 Molecular Cancer Research, 12(1):14–23 Molecular Cancer Research, 12(1):24–31 Molecular Cancer Therapeutics, 13(3):557–64 Cancer Discovery, 4(1):10–11

H.K. Koh (2014) R.S. Herbst, J.A. Hobin, E.R. Gritz; Writing Committee for AACR Tobacco and Cancer Subcommittee (2014) J.-M. Yuan, L.M. Butler, I. Stepanov, and S.S. Hecht (2014) S.S. Hecht and E. Szabo (2014)

D.L. Gibbons, L.A. Byers, and J.M. Kurie (2014) C. Schaal and S.P. Chellappan (2014) J.M. Siegfried (2014) R.N. Pillai and S.S. Ramalingam (2014) S. Rose (2014)

Cancer Discovery, 4(1):12–13 Cancer Discovery, 4(3):265 Cancer Discovery, 4(3):263–4

S. Rose (2014) S. Rose (2014) M. Weber (2014)

Cancer Research, 74(2):401–411

Clinical Cancer Research, 20(2):301–309

Cancer Epidemiology, Biomarkers & Prevention, 23(1):3–9 Cancer Epidemiology, Biomarkers & Prevention, 23(1):32–36 Cancer Epidemiology, Biomarkers & Prevention, 23(1):37–46

Journal

B.A. Toll, A.M. Rojewsi, L.R. Duncan, et al. (2014)

S.A. Glantz and K.C. Johnson (2014)

K. Michael Cummings and R.N. Proctor (2014)

Author(s), y

Title

Table 1. Content in AACR Special Publication Commemorating the 50th Anniversary of the Surgeon General's Smoking and Health Report

Herbst et al.




Table 2. Anti-tobacco initiatives Year

Policy

Importance

Function

1964

1967

FCC Fairness Doctrine

1968

AACR issues first policy statement on smoking

1969 1971

AACR prohibits smoking in meeting rooms at annual meeting Ban on cigarette advertising on TV

1971

Warning labels strengthened

1975

The Minnesota Clean Indoor Air Act

1983

Bipartisan federal cigarette tax increase to $0.16/pack AACR Board of Directors issues position paper: "Smoking and Lung Cancer: An Overview"

Found a causal link between smoking and lung cancer in men Required all cigarette packs to carry health warning labels Required broadcast TV and radio stations to offer time for public service announcements to counter cigarette advertising Encouraged educational and research programs aimed at decreasing smoking and diminishing smoking-associated risk Eliminated exposure of nonsmokers to secondhand smoke Eliminated significant advertising promoting cigarette use Warning labels are strengthened because of mounting evidence of the adverse health effects of smoking First statewide law requiring separate smoking and nonsmoking areas for indoor public spaces Price increases discourage smoking, particularly among youth Called for greater measures to stop smoking, including controls on advertising, improved warning labels, increased tobacco taxes, and elimination of smoking in public places Alerted the public that secondhand smoke is also harmful to health Called for the cessation of government subsidies to the tobacco industry Eliminated exposure of nonsmokers to secondhand smoke Established nicotine as the addicting agent in tobacco Eliminated exposure of nonsmokers to secondhand smoke Strengthened existing financial investment guidelines to exclude investments in tobacco-related companies Price increases discourage smoking, particularly among youth Prohibited targeted marketing to youth and funds counter advertising campaigns Eliminated exposure of nonsmokers to secondhand smoke Price increases discourage smoking, particularly among youth

EDUCATION

1965

Surgeon General's Report on Smoking and Health Cigarette Labeling and Advertising Act

1984

1986

1990

Surgeon General's Report on Involuntary Exposure to Cigarette Smoke AACR issues resolution on tobacco subsidies Smoking banned on U.S. flights under two hours Surgeon General's Report on Nicotine Addiction Smoking banned on all U.S. flights

1990

AACR modifies investment guidelines

1991–1993

Bipartisan federal cigarette tax increase to $0.24/pack Master Settlement Agreement

1987 1988 1988

1998

2000 2000–2002

Smoking banned on all international flights leaving U.S. Bipartisan federal cigarette tax increase to $0.39/pack

WARNING EDUCATION

ADVOCACY

PROTECTION PROTECTION PROTECTION

PROTECTION

PRICE INCREASE ADVOCACY

EDUCATION ADVOCACY PROTECTION EDUCATION PROTECTION ADVOCACY

PRICE INCREASE PROTECTION

PROTECTION PRICE INCREASE

(Continued on the following page)



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Table 2. Anti-tobacco initiatives (Cont'd ) Year

Policy

Importance

Function

2009

AACR Tobacco and Cancer Subcommittee formed

ADVOCACY

2009

Family Smoking Prevention and Tobacco Control Act (TCA)

2009–2014

Implementation of Family Smoking Prevention and Tobacco Control Act

2009

AACR provides input on FDA regulation of tobacco products

2009

Bipartisan federal cigarette tax increase to $1.01/pack The Affordable Care Act

Created to foster scientific and policy initiatives to reduce the incidence of disease and mortality because of tobacco use Formed the FDA Center for Tobacco Products and gave the FDA authority to regulate tobacco products for the first time in the country's history Under TCA, FDA banned fruit and candy flavored cigarettes, restricted marketing to youth, improved warning labels, implemented tobacco product review, and enforced compliance with the law among other measures Encouraged development of reduced harm products, tobacco tracking and surveillance measures, elimination of menthol, stronger warning labels, and other measures Price increases discourage smoking, particularly among youth Authorized funding for smoking prevention efforts and expands access to cessation treatment AACR's most comprehensive statement on tobacco policy recommended investment in tobacco regulatory research and the implementation of evidence-based tobacco control strategies First federally funded national tobacco education campaign—led 100,000 smokers to quit and 1.6 million to attempt to quit Called for assessment and documentation of tobacco use and the provision of evidence-based cessation treatment in all clinical cancer settings Urged FDA to ban the inclusion of menthol in all combustible tobacco products and to explore public health impact of banning other mentholated tobacco products FDA's first national public education campaign targeting at-risk youth ages 12 to 17 years who are open to smoking or already experimenting

2010

2010

AACR Issues "Tobacco and Cancer" policy statement

2012

CDC launches Tips campaign

2013

AACR Issues "Assessing Tobacco Use by Cancer Patients and Facilitating Cessation" policy statement

2013

AACR provides input on FDA regulation of menthol

2014

FDA public education campaign

PROTECTION

PROTECTION WARNING

ADVOCACY

PRICE INCREASE PROTECTION

ADVOCACY

EDUCATION

ADVOCACY

ADVOCACY

EDUCATION

NOTE: Over the past 50 years, numerous federal policies and initiatives have been implemented to reduce smoking and exposure to secondhand smoke. The AACR has long championed such efforts and continues to advocate for evidence-based tobacco control. This table lists major federal and AACR (shaded) milestones. Adapted from American Association for Cancer Research. AACR Cancer Progress Report 2013. Clin Cancer Res 2013;19(Supplement 1):S1-S88.

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smoke-free policies (2). The AACR has been gratified to see progress on many of these fronts. Following the enactment of the TCA, tobacco companies are required to report to the FDA all of the ingredients in their products and all of the harmful or potentially harmful constituents in cigarette smoke. In addition, companies are prohibited from marketing a new product if it is "not shown that the product is appropriate for the protection of the public health" (26). An exception to this prohibition is for products shown to be "substantially equivalent" to a product commercially marketed as of February 15, 2007. In 2013, the FDA used its authority under the "substantial equivalence" pathway for the first time to stop the further sale and distribution of four tobacco products currently on the market after finding that the manufacturer did not show that the product is substantially equivalent to a predicate product or does not raise different questions of public health (27). This is a major step forward for tobacco control efforts. Regulatory actions aimed at reducing the number of dangerous tobacco products available are an important part of the FDA’s regulatory toolkit, but the best way to prevent the harm associated with tobacco is to prevent the initiation of tobacco use. Unfortunately, every day, more than 3,000 American children try a cigarette for the first time and about 700 of these children become daily smokers (28). Preventing today’s children from becoming the next generation of tobacco users is a national policy priority for the AACR. The FDA has taken a number of regulatory actions to curb youth tobacco use, including restricting access and marketing of cigarettes, cigarette tobacco, and smokeless tobacco to youth; enforcing the ban on brand-name tobacco sponsorship of sporting events and concerts; and removing cigarettes with candy and fruit flavorings from the market in order to make them less appealing to kids—all actions that the AACR fully endorses. The AACR has also urged the FDA to include menthol in the ban on so-called "characterizing" flavors based on the scientific evidence that menthol cigarettes increase experimentation and progression to regular smoking, that youth who initiate smoking with menthol cigarettes are more likely to become regular smokers than those who initiate with nonmenthol cigarettes, and that adolescent menthol smokers have a higher prevalence of nicotine dependence and more severe nicotine addiction than those who smoke nonmenthol cigarettes (29). The AACR also noted that the danger of menthol-flavored cigarettes falls disproportionately on African-Americans, who are more likely to smoke this type of cigarette. The FDA has issued an Advance Notice of Proposed Rulemaking on menthol (30), and the AACR is hopeful that a ban is forthcoming. The FDA has also taken steps to educate consumers about the dangers posed by tobacco and to prevent manufacturers from making misleading claims about product safety. In July 2010, an FDA ruling requiring larger and more visible warnings on smokeless tobacco products and advertisements went into effect (31), and the agency implemented TCA provisions prohibiting manufacturers from producing


or distributing any tobacco products labeled or advertised as "light," "low," or "mild" on the grounds that smokers mistakenly believe that these products cause fewer health problems than other cigarettes (32). In addition, in February 2014 the FDA launched its first national public education campaign aimed at reducing the number of young people who use tobacco (33). The campaign targets at-risk 12- to 17-year olds, with a specific focus on rural and racial, ethnic, and sexual minority youth. The AACR strongly supports federal investment in evidence-based media campaigns to end tobacco use, and a review of tobacco control strategies in the 2014 Surgeon General’s Report demonstrates that they have worked. For example, the American Legacy Foundation’s truth campaign, which targeted teens and young adults, was successful in creating a high level of awareness of its messages among the intended target audience and was effective in discouraging youth from smoking (34). Analyses of the Centers for Disease Control’s (CDC) Tips From Former Smokers—the first-ever federally funded national tobacco education campaign— found that an estimated 1.6 million smokers made an attempt to quit and at least 100,000 smokers quit for good as a result of the 2012 campaign (35), spurring the CDC to continue the initiative in 2013 and 2014. The AACR also supports policies that increase the price of tobacco. The 2014 Surgeon General’s Report states that the evidence is sufficient to conclude that increases in the prices of tobacco products prevent initiation of tobacco use, promote cessation, and reduce the prevalence and intensity of tobacco use among kids and adults. Although the last federal increase came under the 2009 Children’s Health Insurance law and added $1.01 tax per pack, several states have increased the cost of cigarettes since then (36), and the average price nationwide is $6.03 per pack, with considerable variability from state to state (37). The AACR also supports smoke-free indoor air policies based on the evidence that smoke-free indoor air policies are effective in reducing exposure to secondhand smoke and lead to less smoking by those affected by the policies. As of January 2, 2014, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and 24 states had laws in effect that require restaurants, bars, and nonhospitality workplaces to be 100% smoke-free. Thirty-six states had laws that required some combination of restaurants, bars, nonhospitality workplaces, and state-run gambling establishments to be smoke-free (38). Toward a tobacco-free future The past 50 years has witnessed a dramatic shift in attitudes among Americans toward tobacco. As the Surgeon General’s Anniversary Report notes, smoking and other forms of tobacco use have gone from a widely accepted element of daily life to a socially unaccepted addiction that is known to be deadly. Comprehensive tobacco control programs and policies such as those described above have cut adult and youth smoking by more than half and have helped to drive the 72% decline in annual adult-per-capita cigarette consumption since 1963 (1). These effective


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gains—and the lives they have saved—are celebrated by the AACR, and should be celebrated by policy makers, health care providers, and research organizations through increased efforts to support tobacco control. Although tremendous progress has been made in reducing the burden of disease, disability, and death caused by tobacco use, there is still a long way to go. The 2014 Surgeon General’s Report is a call to redouble our nation’s commitment to tobacco control. Over 42 million adults and more than 3.5 million adolescents continue to smoke, and smoking remains the leading preventable cause of death worldwide (1). Smoking contributes to at least 30% of all cancers, 87% of lung cancers (39), adverse outcomes in patients with cancer, and to significant morbidity and mortality from many other diseases. Approximately 480,000 Americans die prematurely each year as a result of their addiction, and an estimated 5.6 million children alive today will die early if present smoking trends continue. Large disparities in tobacco use remain across groups defined by race, ethnicity, educational level, socioeconomic status, psychiatric comorbid condition and region (1). Moreover, there is cause for concern over the increase in the use of cigars, pipes, and roll-your-own tobacco even while conventional cigarette smoking has declined (1). In addition, the rapid rise in the use of electronic cigarettes warrants surveillance and study. The AACR strongly supports the goal of the U.S. Department of Health and Human Services to reduce smoking to less than 10% of the total U.S. population in the next 10 years. The 2014 Surgeon General’s Report (1) outlines a number of specific actions for achieving that goal, which include expanding tobacco control and prevention research efforts; effectively implementing the FDA’s authority for tobacco product regulation; continuing to counteract tobacco industry marketing by sustaining high impact national media campaigns; raising taxes on cigarettes; expanding access to smoking cessation services; fully funding comprehensive statewide tobacco control programs at levels recommended by the CDC; and extending comprehensive smokefree indoor protection to 100% of the U.S. population. The AACR championed many of these recommendations in its 2010 Tobacco and Cancer policy statement (2) and subsequent advocacy activities, and we are committed to their implementation. The 2013 AACR policy statement addressing tobacco use by patients with cancer (18) provided preemptive support for the evidence presented in the 2014 Surgeon General’s Report by recognizing the need to continue to address tobacco use even after a cancer diagnosis. In addition to continuing to combat the use of cigarettes and other conventional tobacco products, the AACR is developing a policy statement on electronic cigarettes that is expected to address research needs in this area, provide guidance to health care providers for discussing ecigarettes with patients, and include recommendations for regulating these products. Although the majority of the AACR’s work in tobacco control policy has focused on stemming the tide of tobaccorelated death and disease in the United States, we are

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mindful of the dire global burden of tobacco use. Although the global prevalence of daily smoking declined from 1980 to 2012, the absolute number of smokers has increased from 721 million to 967 million during this time period, and there are preliminary indications that global prevalence among men increased in recent years (40). Ten percent of all deaths worldwide in 2015 are projected to be because of tobacco use (1). Meanwhile, the tobacco industry has used international trade and investment agreements to undermine global tobacco control efforts, challenging laws requiring warning labels and plain packaging for tobacco products as well as restrictions on tobacco product imports (41). The AACR strongly encourages the United States to pursue economic policies that support tobacco control and to ratify the World Health Organization’s Framework Convention on Tobacco Control, a first-of-its-kind treaty adopted by most other countries that requires parties to implement evidence-based tobacco control measures. The AACR looks forward to working with researchers, clinicians, advocates, and policy makers in the United States and abroad toward a tobacco-free world.

AACR Tobacco and Cancer Subcommittee Roy S. Herbst, MD, PhD Chairperson Yale Cancer Center, Yale University School of Medicine, New Haven, CT Denise Aberle, MD University of California, Los Angeles, Los Angeles, CA Thomas H. Brandon, PhD H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL Geoffrey T. Fong, PhD University of Waterloo, Waterloo, Ontario, Canada; and Ontario Institute for Cancer Research, Toronto, Ontario, Canada Jennifer Rubin Grandis, MD University of Pittsburgh School of Medicine, Eye and Ear Institute, Pittsburgh, PA Ellen R. Gritz, PhD The University of Texas MD Anderson Cancer Center, Houston, TX Dorothy K. Hatsukami, PhD University of Minnesota, Minneapolis, MN Ernest Hawk, MD, MPH The University of Texas MD Anderson Cancer Center, Houston, TX Waun Ki Hong, MD, DMSc (Hon.) The University of Texas MD Anderson Cancer Center, Houston, TX Fadlo R. Khuri, MD Winship Cancer Institute, Emory University, Atlanta, GA Scott J. Leischow, PhD Mayo Clinic, Scottsdale, AZ Peter G. Shields, MD Comprehensive Cancer Center, The Ohio State University Medical Center, Columbus, OH




Benjamin A. Toll, PhD Yale Cancer Center, Yale University School of Medicine, New Haven, CT Kasisomayajula (Vish) Viswanath, PhD Harvard School of Public Health, Dana-Farber Cancer Institute, Boston, MA Graham Warren, MD, PhD Hollings Cancer Center, Medical University of South Carolina, Charleston, SC Stephanie R. Land, PhD, ex officio (NCI liaison) National Cancer Institute, Rockville, MD

Jennifer A. Hobin, PhD (AACR staff liaison) American Association for Cancer Research, Washington, DC Member of Writing Committee Acknowledgments The Tobacco and Cancer Subcommittee of the AACR Science Policy and Government Affairs (SPGA) Committee oversaw the development of this manuscript, which was prepared by a Writing Committee. Special thanks are extended to Dr. Arthur Buchberg and Dashiell Delan for research and editorial assistance. Received February 20, 2014; accepted February 20, 2014; published online April 1, 2014.

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AACR Celebrates 50 Years of Tobacco Research and Policy Roy S. Herbst, Jennifer A. Hobin and Ellen R. Gritz Clin Cancer Res 2014;20:1709-1718.

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