Lung Cancer Prevention in South
Carolina and Beyond
K. Michael Cummings, PhD, MPH
Professor,
Department of Psychiatry & Behavioral
Sciences and Co-Director of Tobacco
Policy and Control Hollings Cancer
Education & Experience
 Education
 BS, Health Education, Miami University (Ohio), 1975
 MPH, Health Behavior, University of Michigan, 1977
 PhD, Health Behavior, University of Michigan, 1980
 Past Experience
 Senior Scientist & Chair, Department of Health Behavior, Roswell Park





Cancer Institute
Professor, Department of Social & Preventive Medicine, SUNY @
Buffalo
Founder and Director, New York State Smokers’ Quit Line
Consultant to the FDA, CDC, and several state based tobacco coalitions
Recipient of numerous (>40) NIH grants and contracts
Contributor to several past Surgeon General’s Reports, IOM reports,
NIH and IARC monographs, and author/co-author of >300 peer
reviewed papers
Preventing Lung Cancer
Background
• 1/3rd of cancer deaths are the result of cigarette smoking
• 85-90% of lung cancer is due to smoking
• Duration of smoking is the strongest predictor of cancer
risk
• Nicotine addiction is the primary reason by people
continue to smoke for decades despite awareness of
health risks
Annual number of reported lung cancer deaths
1890-2009 (USA)
(1)
1890’s
145
1930
<3,000
1950
18,000
1955
27,000
1962
41,000
2009
159,390
(1)
1964 Surgeon General’s Advisory Committee (Page 25) and the
American Cancer Society. Cancer Facts & Figures 2009
Changes In Tobacco Use Behaviors
Trends in Per Capita Consumption of Various Tobacco
Products – United States, 1880-2003
16
Cigarettes
Cigars
Pipe/Roll your own
Chewing
Snuff
14
POUNDS
12
10
8
6
4
2
1880
1885
1890
1895
1900
1905
1910
1915
1920
1925
1930
1935
1940
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
0
YEAR
Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census
Note: Among persons > 18 years old.
Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff. Estimates for 2002 and 2003 are preliminary.
Chesterfield, 1918
Camel, 1913
Lucky Strike, 1916
My goal…
 The overarching goal of my research program is to
move the mortality curve from tobacco induced
cancers downward.
This is not a pipe dream...
Annual change = -0.5%*
80
70
Rate Per 100,000
60
Annual change= -1.6%*
50
40
30
20
California
United States (minus California)
Poly. (California)
10
Poly. (United States (minus
California))
0
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Rates are per 100,000 and age-adjusted to the 2000 U.S. standard (19 age groups).
* The annual percent change is significantly different from zero (p<0.05).
Source: Cancer Surveillance Section. Prepared by: California Department of Public Health, California Tobacco Control Program, 2008.
Our Challenge: Speed of Action Matters
Estimated cumulative tobacco deaths
1950-2050
520
Tobacco deaths (millions)
500
500
400
340
300
Impact of policies
depends on factors
including:
– Intervention date
220
200
– Effect size
190
100
70 A reduction of 10% in cigarette consumption today would
0
prevent an estimated 10 million cancer deaths by 2030
1950
2000
2025
2050
Year
World Bank. Curbing the epidemic: Governments and the economics of tobacco
control. World Bank Publications, 1999. p80.
Research Themes
How do we get fewer people to use tobacco?
 What is the impact of government policies on uptake of tobacco
(taxes, smoke-free rules, warning labels, marketing restrictions,
product regulations)
How can we get more tobacco users to quit using
tobacco?
 What tobacco cessation methods or combination of methods work
best and how can outcomes be improved upon by matching
treatments to patient characteristics?
 What factors influence a person’s motivation to quit?
 What factors influence a person’s ability to quit permanently (i.e.,
biology vs environment)?
Research themes
Among those either unwilling or unable to quit, are their
strategies to mitigate their risk of developing cancer?
 Are smokers willing to substitute less dangerous alternative forms of
nicotine delivery?
 How can tobacco products be made safer to use and what is the impact of
product modifications on continued tobacco use (e.g., lower nicotine levels
in products; ban filter vents; alter tobacco blends)
Among those who do stop using tobacco, but remain at
elevated risk of cancer is there anything they can do to lower
their future risk of cancer?
 What factor predict someone’s future risk of developing a tobacco caused
cancer?
 What screening methods or combination of methods can reduce cancer
mortality?
 What are unintended consequences of screening?
 What screening protocols work best (i.e., who and how often)?
Outline
Examples of past and current research
• International tobacco control policy research project
Future vision
• South Carolina Lung Cancer Prevention Study
• Center of Excellence for research focused on the
recalcitrant smoker
• Enhancing evidence based tobacco control in South
Carolina
Goal – build the evidence base for public
health interventions to control tobacco
Goal 1: Conduct rigorous evaluation of national-level
tobacco control policies of the WHO’s Framework
Convention on Tobacco Control (FCTC)
Goal 2: To understand how and why these policies work
(if they work)
Policy
?
Behavior
What’s inside the black box?
Goal 3: Compare how policy effects work across
different countries (high v. low income)
Key requirements of FCTC

Price and tax measures to reduce demand (Article 6)

Protection from exposure to tobacco smoke (Article 8)

Regulation of the contents of tobacco products (Article 9)

Regulation of tobacco product disclosures (Article 10)

Packaging and labelling (Article 11)
 Warnings
 Elimination of misleading descriptors (e.g., “light”
“mild”)

Education, communication, training, public awareness
(Article 12)

Ban tobacco advertising, sponsorship and promotion
(Article 13)

Dependence and cessation treatments (Article 14)
A global problem requires a global solution
Framework Convention on Tobacco Control (FCTC) adopted in 2003
>170 Contracting Parties
Common features of ITC Projects
Natural experiments
 Strategic selection of different countries based on policies
Common set of measures
 Theory driven mediational model of how policies work
Common data collection protocols
 Cohort studies with probability samples of smokers
(n~2000) surveyed annually in each country
ITC 2004…
2011…
Six countries: USA, Canada, UK, Australia, Thailand, Malaysia
21 countries
Translating research to practice…
US Product warnings
The rest of there world
Vision for the future...
• South Carolina Lung Cancer Prevention Study
• Center of Excellence for research focused on the
recalcitrant smoker
• Enhancing evidence based tobacco control in South
Carolina
South Carolina Lung Cancer Prevention Study:
a population based initiative to…
• Recruit high risk (30+ pack years)
current and former smokers through
primary care offices, hospitals, quit
lines, and self-referral
• Provide incentives to stop smoking
and get screened
• Track participants to ensure repeat
screening and maintenance of
smoking cessation
• Compare rates of late stage lung
cancer over time
The problem…
Today, ~50% of lung cancers are found
in former cigarette smokers
> 2/3rds of lung cancer are found in a
late stage where therapeutic
interventions are largely unsuccessful
A Solution…
Early detection and surveillance with
low dose spiral CT scanning can find
cancers early and reverse the trend in
late stage detection
Key Findings from NLST
 20% reduction in lung cancer
mortality in the LDCT group
compared to the CXR group.
 All cause mortality was lower in
the LDCT group compared to the
CXR group.
 The stage of lung cancer was
shifted to earlier, resectable
cancers in the LDCT group
compared to the CXR group.
Key Findings
 There were dramatically more
positive tests in the LDCT group.
The challenge…
How should we translate the NSLT
findings into a population based
intervention that in South Carolina can
reduce late stage lung cancer detection?
• How will we get the people who
will benefit the most from
screening, screened?
• How do we use screening as an
opportunity to promote smoking
cessation?
• How do we ensure high quality
service delivery and repeat
screening?
The problem with current
standard of care
 Delivery of smoking cessation and early detection
services are haphazard and rarely done in
combination
 Interventions when delivered are often only done
once even though long term adherence is necessary
to get the benefit
Recruitment – create a registry
The Plan
High Risk:
55-74 years of age
30 pack-years of smoking
Potentially some restriction by years since quitting smoking
OR
50 years old or greater
> 20 pack-years of smoking
One other lung cancer risk factor (COPD, asbestos exposure,
family history)
Enrollment-Three Channels for Client Access:
1.Health Care Setting Enrollment
2.Call Center Enrollment (Quit Line)
3. Self-referral vis online enrollment
For those recruited…
Add an Integrated Technology Solution
Combining IVR & Smart Card Technology

A “SmartCard” sent to them in the mail that offers
discounts on purchases for…
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Stop smoking medications
Low dose spiral CT scanning at approve screening centers to
ensure quality control
Routine reminders and counseling via phone, e-mail, text
messaging to keep participants engaged in the intervention
Smart Card Technology
 Proven mechanism for distribution
and tracking of medications and
medical services
 Allows for choice and flexibility
since incentives can be varied and
altered over time
 Data capture is time stamped and
real-time.
Follow-up / Triage
• IVR - an evidence based
method of communicating
with patients systematically
• Scheduled emails with
linkage to secure web
pages
• Mobile smart phone Apps
• Connects clients to live
counseling when needed
Primary outcomes
 % of late stage lung cancer in defined region, e.g., state of
South Carolina
 % of lung cancer patients alive after 10 years
The result…
• We will learn if a combined prevention and screening
regimen can accelerate the decline in lung cancer
mortality (if this works – this will be the standard of care)
• The recruited cohort of subjects could be used to spin off
additional studies within the program, e.g.,…
– Methods for subject recruitment and ways to reduce disparities in
delivery of lung cancer prevention interventions
– Optimum screening protocols and studies of how to handle
patients with positive screening findings
– The value of different biomarkers for early detection of disease
– Testing of new tobacco cessation treatments and combinations
Questions