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From the IASLC Tobacco Control Committee

        Latest Tobacco Research

        Smoking cessation (SC) and lung cancer (LC) outcomes: A survival benefit for recent-quitters? A pooled analysis of 34,649 International Lung Cancer Consortium (ILCCO) patients

        The authors examined 17 studies in the International Lung Cancer Consortium (ILCCO) database to determine if smoking cessation prior to lung cancer diagnosis is associated with better overall survival (OS) and lung cancer specific survival (LCSS), considering time since smoking cessation (TSSC). Of 34,649 patients, current smokers, ex-smokers, and never smokers accounted for 41%, 41%, and 18%, respectively. Improved OS was observed in ex-smokers (adjusted hazard ratios [aHR] 0.88) and never smokers (aHR 0.76) compared with current smokers. Among ex-smokers, the risk of overall death was reduced by 12% on < 2y TSSC, 17% on 2-5y TSSC and 20% > 5y TSSC, whereas for LCSS, the benefit was significant only for > 5y TSCC, compared to current smokers at time of diagnosis. Analysis of > 30 pack-years individuals showed improved OS by 14% on < 2y TSSC, 17% on 2-5y TSSC, and 22% on > 5 TSSC, compared to current smokers. Similar trend was observed for < 30 packs-years. In summary, the study demonstrated that, regardless of pack-years, age, stages and other prognostic variables, improved OS was observed by convincing screening participants to quit smoking at any point of their trajectory, and LCSS benefit was observed beyond 5 y of quitting.
        Fares AF, Jiang M, and Yang P et al. Smoking cessation (SC) and lung cancer (LC) outcomes: A survival benefit for recent-quitters? A pooled analysis of 34,649 International Lung Cancer Consortium (ILCCO) patients. J Clin Oncol 38: 2020 (suppl; abstr 1512). https://doi.org/10.1200/jco.2020.38.15_suppl.1512.

        Long-term Outcomes of a Preoperative Lung Resection Smoking Cessation Program

        A retrospective study of prospective database was conducted to analyze the long-term outcomes of an intensive, preoperative smoking cessation program in patients undergoing lung resection (2015-2017). Of the total 340 patients underwent lung resection, 82 patients were current smokers. All were advised to quit and encouraged to meet with a certified tobacco treatment specialist. Sixty-three patients met with a certified tobacco treatment specialist. Sixty patients (73%) were able to quit before surgery. Excluding deaths (n=9, 11%) and those lost to follow-up (n=15, 18%) at 2-year postoperatively, cessation rates at 6, 12, and 24 months postoperatively were 55.3%, 55.6%, and 51.7%, respectively. To conclude, the findings suggest that high initial, mid-term, and long-term success rates could be achieved with the implementation of an intensive smoking cessation program in the preoperative period, especially in lung cancer with a high rate of cessation up to 2 years post-surgery.
        Phillips JD, Fay KA, Ramkumar N, Hasson RM, Fannin AV, Millington TM, Finley DJ. Long-term Outcomes of a Preoperative Lung Resection Smoking Cessation Program. J Surg Res. 2020;254:110-7. Epub 2020/05/20. https://doi.org/10.1016/j.jss.2020.04.005. PubMed PMID: 32428728.

        Tobacco News Update

        The Great Plain Packaging Case

        Australia woke the other morning to some remarkable and gratifying news. No, not the low COVID-19 caseload experienced by this island nation and not the gradual easing of restrictions with the much-anticipated restart of the rugby season. The news had to do with the slow pandemic, not the fast one and heralded the end of the final chapter in the tobacco industry’s attempt to block the introduction of cigarette plain packaging. This was announced on Australian radio on June the 11th (1) with an interview with a lawyer from the McCabe Centre for Law and Cancer (2). As made clear in this interview, the tobacco industry has used three types of legal action to oppose the introduction of plain packaging: (a) direct challenges in Australia’s High Court, (b) challenges under an international trade treaty with Hong Kong (3) and (c) appeals made directly to the World Trade Organization (WTO). The actions contested the legitimacy of plain packaging based on trade arguments. The final appeal was brought by Honduras and the Dominican Republic (reportedly funded by the tobacco industry) after other countries involved in initial proceedings (Ukraine, Indonesia and Cuba) withdrew or were dismissed. According to the McCabe lawyer, this latest appeal was the last of the outstanding legal proceedings against plain packaging. Australia’s win clears the way for other countries keen to introduce the changes. The decision comprehensively deals with the legal issues around plain packaging (that it does not violate international trade law and that it does make a meaningful contribution to public health) and will likely give other countries more confidence to go on.
        The McCabe Centre website provides a written summary of the decision by the WTO (4), quoting the finding of the panel that plain packaging reduces “the use of, and exposure to, tobacco products” (ref 4, para 3). This decision upheld a previous WTO ruling from 2018 (5) and rejected the subsequent appeal from Honduras and the Dominican Republic. The McCabe Centre points to a report released in 2016 that linked plain packaging to a significant decline in smoking prevalence in Australia and estimated a consequent reduction in the number of smokers by more than 100,000 (6). The formal report (7), available from the Australian Department of Health (6) shows the decline in overall smoking prevalence in Figure 1 on page 12 with an encouraging downwards angle in the years following 2012.
        This story has gone on for so long that it has been easy to forget. Everything is easy to forget at the moment if it does not relate directly to COVID-19, or to one or two other dramatic news events of the moment. Here at the News we have followed the plain packaging story and the legal cases for YEARS. Nearly half of all News columns contain reference to the issue of plain packaging, including the very first column from May 2014 (8). And you thought lockdown went on too long. We can construct a timeline of major legal events in the history of plain packaging that begins in 2008, when the tobacco industry started to object to plain packaging and goes right through till now, twelve years later. A 2018 report from the University of Melbourne (9) summarizes the “long line of litigation” (ref 9, para 19), that includes multiple international court cases and that has finally come to an end with the 2020 decision by the WTO in favor of the Australian government.
        The Global Tobacco Control website (10) provides a further list of countries with full implementation of plain packaging laws (France, the United Kingdom, New Zealand, Norway, Ireland, and Saudi Arabia) and those countries with laws that await implementation (Thailand, Uruguay, Slovenia, Turkey, Israel, Canada, Singapore, Belgium, and Hungary). This link also provide guidance for low and middle-income countries that may be interested in plain packaging, summarized in a one-page report that includes suggestions for mock-ups, focus groups and the importance of a political champion (11). The industry will think of something to interfere with this. They have never gone quietly. But at least for the moment, this column will smile and enjoy such a lovely conclusion.

        Retraction

        Observant readers will have noted the recent Lancet retraction of a paper that investigated hydroxychloroquine for treatment of COVID-19 (12). In last month’s News we referenced a paper by the same group that has also been retracted (13). For both papers, concerns about the quality of the (same) database led to the retraction. We remain interested in the links between current smoking status and COVID-19 disease and note the publication since our last column, of another systematic review (14). This paper reports an odds ratio of 1.98 for severe COVID-19 in current smokers, a statistic we will watch as the COVID-19 literature matures.

        Too soon to tell

        The information on COVID-19 comes in fast. We talked about the COVID paper “torrent” last month (15) and it is still going. Concerns have arisen about smoking rates during the pandemic and plenty of questions remain. Will lockdown make it harder to quit, through lack of access to cessation support as well as through general misery (16)(17)? Will COVID-19 scare people into quitting (18) and dent business for the tobacco industry? (19) Can we be enterprising and catch the COVID momentum to help people quit (see #QuitforCovid from the UK (20))? Will e-cigarettes take advantage of our distraction and maintain their appeal to young people, even those with cancer (21)? Will that other driver of chaos, Brexit, mess with Britain’s attempts to introduce a ban on menthol cigarettes? (22). The big, old-fashioned court-case win in the WTO (above) feels good, but may not curb the stealth tactics of the “new normal” in tobacco, such as payments to “influencers” to manipulate the image of tobacco on social media (23). Two internationally recognized Australian public health experts comment on the COVID-19 “exit strategy” (24) that at least in some countries, has been taking effect. This includes big steps taken fast - social and economic restrictions, government spending, huge changes in the behavior of whole populations and the ready acceptance by government of public health advice. All with strong community support. Think slow, imagine a little and apply these principles to tobacco. Wow.