Editorial

Tobacco, alcohol and cancer: Not always black and white

“We always need to hear both sides of the story.”

– Phil Collins

The mother of a friend and former colleague of mine was recently admitted to our facility for evaluation of a lung mass.

John Sweetenham, MD, FRCP, FACP
John Sweetenham

An initial biopsy indicated a diagnosis of non-small cell lung cancer. A subsequent video-assisted thoracoscopic surgery showed disease infiltrating the pericardium, considered to be inoperable.

In view of her advanced age and poor performance status, she was not considered a candidate for further systemic therapy. She was discharged back to home following a palliative care referral and connected with a local hospice.

She has been doing well on home hospice care. She has been a smoker for more than 60 years.

This story reinforced my belief that we need to do more to reduce the health care burden — both at the societal and individual levels — that is caused by the use of tobacco in all forms.

Issues of going tobacco free

The timing of this woman’s admission to our facility coincided closely with major steps in our ongoing efforts to establish a tobacco-free campus at my institution. It may seem surprising that our campus has not had a tobacco-free policy — especially given the strong cancer care presence — but we have been working on establishing such a policy for many months.

I have been, and remain, a passionate advocate for removing tobacco from our campus, but have had to adjust my thinking on this issue as we have been going through the process of establishing this rule. I thought this was a simple black-and-white issue, with no gray in between. Tobacco use is the leading cause of preventable illness and death in the United States, and any suggestion that we enable this behavior on our campus is contrary to our mission as a health care organization, and more specifically as a cancer center.

As we have developed policies, and plans for implementing these across the campus, I began to understand that many people see this issue very differently.

One of the major concerns expressed by those outside the health care environment has been the infringement of individual rights. The counterpoint to this are the known health risks from secondary smoking — a powerful argument in favor of a complete tobacco ban. That said, what about smoking in open spaces on campus, or the use of chewable tobacco? Arguments of secondary health risks to others don’t hold water in these examples.

Another concern has been the potentially judgmental nature of smoker victimization and the perception of a tobacco ban as a punitive measure. Interestingly, this has been expressed particularly strongly by employees.

Although those of us who advocate for a smoking ban sincerely believe that our actions are not judgmental, we are not always perceived as such. A report from ASCO regarding the cancer risks associated with alcohol use (see page 7) has made me wonder whether we are totally free of bias in this regard — more on this to follow.

Other very reasonable concerns for this new policy include how this will be enforced without a punitive approach, how we will address the needs and engagement of the members of our workforce who smoke, and how we will address the needs of potentially terminally ill patients in our facility who may wish to use tobacco at the end of their lives.

Opinions on these questions are variable. However, we of course recognize the need for active tobacco cessation programs for our staff and patients, as well as the need for a supportive rather than punitive environment. We are developing strategies to help with these concerns and have the experience of the American Cancer Society, as well as many other institutions, to guide us.

We also have well-developed, strong rationale for the tobacco restriction, including limiting secondhand smoking; providing a supportive environment for those who want to quit; supporting a healthy campus environment, as well as green initiatives; and reducing costs associated with fire and medical insurance rates, cleaning, maintenance, absenteeism and health care.

I have no doubt that we are taking the right approach, consistent with many other institutions who have made this journey. But the process has taught me that there are other, very valid, opposing opinions. I have gained a heightened awareness of the sensitivity of this subject, and understand that there is some “gray” to this issue, which is not the place from which I started.

Attitudes on alcohol

ASCO’s new alcohol and cancer statement also has made me rethink my own attitudes toward tobacco restrictions.

Most of us have been aware of the cancer risks associated with alcohol use for many years, but the publication from ASCO shows a new perspective, especially with the observation that there is probably no safe level of alcohol consumption, and that the heart-health benefits associated with moderate alcohol use may have been overestimated.

The ASCO statement is a well-written, data-rich and thoughtful description of the relationship between alcohol consumption and cancer. It has many recommendations on the restriction of alcohol use and sales to younger citizens, increased taxation, and the limitation of the density of alcohol outlets by zoning restrictions.

These are all reasonable recommendations, but they fall short of the stringent restrictions that ASCO — and most of us — would like to see strengthened for tobacco products.

I don’t have an evidence-based explanation for this apparent double standard, but I wonder how much it relates to the fact that drinking alcohol — although known to have major risks to health, and high potential for addiction, like tobacco — is regarded by most as an acceptable and enjoyable social behavior. Personally, I enjoy a drink and — to my earlier point regarding a judgmental stance on tobacco use — regard this as an acceptable and social behavior for others.

I don’t regard smoking in the same way and have to ask myself whether that has influenced my attitudes toward smokers. The ASCO statement recommended that oncologists counsel their patients on the use of alcohol and encourage them to reduce or eliminate their alcohol consumption. I wonder how many of us will feel committed to doing so with the same emphasis that we have on smoking cessation?

Given the overwhelming evidence, it’s essential that, as oncologists, we advocate for severe limitations on tobacco with our patients and at a societal level.

Based on emerging evidence, we should be developing stronger messages for alcohol use as well. In doing so, we — or at least I — need to recognize the potential for unconscious bias and understand that these are much more complex and sensitive issues than we sometimes appreciate.

Phil Collins has a good point.

Reference:

LoConte NK, et al. J Clin Oncol. 2017;doi:10.1200/JCO.2017.76.1155.

For more information:

John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is senior director of clinical affairs and executive medical director of Huntsman Cancer Institute at University of Utah. He can be reached at john.sweetenham@hci.utah.edu.

Disclosure: Sweetenham reports no relevant financial disclosures.

“We always need to hear both sides of the story.”

– Phil Collins

The mother of a friend and former colleague of mine was recently admitted to our facility for evaluation of a lung mass.

John Sweetenham, MD, FRCP, FACP
John Sweetenham

An initial biopsy indicated a diagnosis of non-small cell lung cancer. A subsequent video-assisted thoracoscopic surgery showed disease infiltrating the pericardium, considered to be inoperable.

In view of her advanced age and poor performance status, she was not considered a candidate for further systemic therapy. She was discharged back to home following a palliative care referral and connected with a local hospice.

She has been doing well on home hospice care. She has been a smoker for more than 60 years.

This story reinforced my belief that we need to do more to reduce the health care burden — both at the societal and individual levels — that is caused by the use of tobacco in all forms.

Issues of going tobacco free

The timing of this woman’s admission to our facility coincided closely with major steps in our ongoing efforts to establish a tobacco-free campus at my institution. It may seem surprising that our campus has not had a tobacco-free policy — especially given the strong cancer care presence — but we have been working on establishing such a policy for many months.

I have been, and remain, a passionate advocate for removing tobacco from our campus, but have had to adjust my thinking on this issue as we have been going through the process of establishing this rule. I thought this was a simple black-and-white issue, with no gray in between. Tobacco use is the leading cause of preventable illness and death in the United States, and any suggestion that we enable this behavior on our campus is contrary to our mission as a health care organization, and more specifically as a cancer center.

As we have developed policies, and plans for implementing these across the campus, I began to understand that many people see this issue very differently.

One of the major concerns expressed by those outside the health care environment has been the infringement of individual rights. The counterpoint to this are the known health risks from secondary smoking — a powerful argument in favor of a complete tobacco ban. That said, what about smoking in open spaces on campus, or the use of chewable tobacco? Arguments of secondary health risks to others don’t hold water in these examples.

PAGE BREAK

Another concern has been the potentially judgmental nature of smoker victimization and the perception of a tobacco ban as a punitive measure. Interestingly, this has been expressed particularly strongly by employees.

Although those of us who advocate for a smoking ban sincerely believe that our actions are not judgmental, we are not always perceived as such. A report from ASCO regarding the cancer risks associated with alcohol use (see page 7) has made me wonder whether we are totally free of bias in this regard — more on this to follow.

Other very reasonable concerns for this new policy include how this will be enforced without a punitive approach, how we will address the needs and engagement of the members of our workforce who smoke, and how we will address the needs of potentially terminally ill patients in our facility who may wish to use tobacco at the end of their lives.

Opinions on these questions are variable. However, we of course recognize the need for active tobacco cessation programs for our staff and patients, as well as the need for a supportive rather than punitive environment. We are developing strategies to help with these concerns and have the experience of the American Cancer Society, as well as many other institutions, to guide us.

We also have well-developed, strong rationale for the tobacco restriction, including limiting secondhand smoking; providing a supportive environment for those who want to quit; supporting a healthy campus environment, as well as green initiatives; and reducing costs associated with fire and medical insurance rates, cleaning, maintenance, absenteeism and health care.

I have no doubt that we are taking the right approach, consistent with many other institutions who have made this journey. But the process has taught me that there are other, very valid, opposing opinions. I have gained a heightened awareness of the sensitivity of this subject, and understand that there is some “gray” to this issue, which is not the place from which I started.

Attitudes on alcohol

ASCO’s new alcohol and cancer statement also has made me rethink my own attitudes toward tobacco restrictions.

Most of us have been aware of the cancer risks associated with alcohol use for many years, but the publication from ASCO shows a new perspective, especially with the observation that there is probably no safe level of alcohol consumption, and that the heart-health benefits associated with moderate alcohol use may have been overestimated.

The ASCO statement is a well-written, data-rich and thoughtful description of the relationship between alcohol consumption and cancer. It has many recommendations on the restriction of alcohol use and sales to younger citizens, increased taxation, and the limitation of the density of alcohol outlets by zoning restrictions.

PAGE BREAK

These are all reasonable recommendations, but they fall short of the stringent restrictions that ASCO — and most of us — would like to see strengthened for tobacco products.

I don’t have an evidence-based explanation for this apparent double standard, but I wonder how much it relates to the fact that drinking alcohol — although known to have major risks to health, and high potential for addiction, like tobacco — is regarded by most as an acceptable and enjoyable social behavior. Personally, I enjoy a drink and — to my earlier point regarding a judgmental stance on tobacco use — regard this as an acceptable and social behavior for others.

I don’t regard smoking in the same way and have to ask myself whether that has influenced my attitudes toward smokers. The ASCO statement recommended that oncologists counsel their patients on the use of alcohol and encourage them to reduce or eliminate their alcohol consumption. I wonder how many of us will feel committed to doing so with the same emphasis that we have on smoking cessation?

Given the overwhelming evidence, it’s essential that, as oncologists, we advocate for severe limitations on tobacco with our patients and at a societal level.

Based on emerging evidence, we should be developing stronger messages for alcohol use as well. In doing so, we — or at least I — need to recognize the potential for unconscious bias and understand that these are much more complex and sensitive issues than we sometimes appreciate.

Phil Collins has a good point.

Reference:

LoConte NK, et al. J Clin Oncol. 2017;doi:10.1200/JCO.2017.76.1155.

For more information:

John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is senior director of clinical affairs and executive medical director of Huntsman Cancer Institute at University of Utah. He can be reached at john.sweetenham@hci.utah.edu.

Disclosure: Sweetenham reports no relevant financial disclosures.