AACR Celebrates 50 Years of Tobacco Research and Policy
Authors: Roy S. Herbst, Jennifer A. Hobin, Ellen R. Gritz
Journal: Clinical Cancer Research (2014)

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 causes increased overall and cancer-specific mortality as well as increased risk of a second primary cancer.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 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% 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 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.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 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).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 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 smoke-free 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 e-cigarettes 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 tobacco-related death and disease in the United States, we are 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.Roy S. Herbst, MD, PhD*ChairpersonYale Cancer Center, Yale University School of Medicine, New Haven, CTDenise Aberle, MDUniversity of California, Los Angeles, Los Angeles, CAThomas H. Brandon, PhDH. Lee Moffitt Cancer Center and Research Institute, Tampa, FLGeoffrey T. Fong, PhDUniversity of Waterloo, Waterloo, Ontario, Canada; and Ontario Institute for Cancer Research, Toronto, Ontario, CanadaJennifer Rubin Grandis, MDUniversity of Pittsburgh School of Medicine, Eye and Ear Institute, Pittsburgh, PAEllen R. Gritz, PhD*The University of Texas MD Anderson Cancer Center, Houston, TXDorothy K. Hatsukami, PhDUniversity of Minnesota, Minneapolis, MNErnest Hawk, MD, MPHThe University of Texas MD Anderson Cancer Center, Houston, TXWaun Ki Hong, MD, DMSc (Hon.)The University of Texas MD Anderson Cancer Center, Houston, TXFadlo R. Khuri, MDWinship Cancer Institute, Emory University, Atlanta, GAScott J. Leischow, PhDMayo Clinic, Scottsdale, AZPeter G. Shields, MDComprehensive Cancer Center, The Ohio State University Medical Center, Columbus, OHBenjamin A. Toll, PhDYale Cancer Center, Yale University School of Medicine, New Haven, CTKasisomayajula (Vish) Viswanath, PhDHarvard School of Public Health, Dana-Farber Cancer Institute, Boston, MAGraham Warren, MD, PhDHollings Cancer Center, Medical University of South Carolina, Charleston, SCStephanie R. Land, PhD, ex officio (NCI liaison)National Cancer Institute, Rockville, MDJennifer A. Hobin, PhD (AACR staff liaison)*American Association for Cancer Research, Washington, DC*Member of Writing CommitteeThe 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.