Tony Gwynn’s baseball career was the stuff of sports legend. During 20 seasons with the San Diego Padres, the likable lefty racked up more than 3,000 hits, earned eight National League batting titles and was selected for the All-Star Game 15 times. After his final season with the Padres, in 2001, he became a coach at San Diego State University, and in 2007, he was elected to the National Baseball Hall of Fame.
Like many ballplayers, Gwynn, who died of salivary gland cancer in June 2014 at age 54, chewed tobacco through most of his career. And in the years before his death, he publicly blamed tobacco for his cancer, which doctors had discovered in 2010.
Though no studies have conclusively linked tobacco to salivary gland cancer, Gwynn’s death has reignited public awareness about the strong role of tobacco—whether smoked or chewed—as both a cause of cancer and an impediment to its treatment.
For half a century, researchers and health officials have urged the public to acknowledge a tobacco-cancer link. Today, there is an even better understanding of the increased cancer risk associated with using tobacco. According to the American Cancer Society (ACS), tobacco use has been linked to cancer in many different parts of the body, including the bladder, cervix, colon and rectum, esophagus, kidneys, lungs, mouth, nasal cavity, ovaries, pancreas, stomach and throat. Its use is responsible for about 30 percent of cancer deaths in the United States.
For tobacco users who already have cancer, studies show that quitting can lengthen survival, improve the safety and effectiveness of treatment, decrease treatment-related toxicity, and enhance quality of life. Getting off tobacco can also reduce a cancer patient’s risk of recurrence and secondary tumors. “It’s never too late to quit,” says thoracic oncologist Roy Herbst, the chief of oncology at Yale Cancer Center in New Haven, Connecticut. “A person can always make a positive impact on health by quitting tobacco.”
Of course, quitting is easier said than done. According to the U.S. Centers for Disease Control and Prevention (CDC), nicotine may be as addictive as heroin, cocaine and alcohol. Meanwhile, studies suggest most physicians don’t develop quit plans with their patients. Adding to the challenge, tobacco users who have cancer are frequently blamed for causing their illness, a stigma that can impede both a patient’s ability to cope with a diagnosis as well as research and health care for patients with tobacco-associated cancers.
But those who want to kick the habit should take heart: Doctors have gained a better understanding of tobacco’s addictive potency, and that knowledge is driving new approaches to help people quit. Likewise, patients and researchers are focusing on ways to move beyond the tobacco stigma to improve patient care and support.
Quitting tobacco can improve the effectiveness of cancer treatment and increase a patient’s quality of life and survival. But whether users smoke or chew, the nicotine in tobacco is highly addictive, and quitting can be daunting. In a study of almost 3,000 cancer survivors, including smokers and non-smokers, published in September 2014 in
Cancer Epidemiology, Biomarkers & Prevention, American Cancer Society (ACS) researcher J. Lee Westmaas and his colleagues reported that nearly 10 percent were smoking nine years after diagnosis. About two-thirds of survivors who had smoked at diagnosis were still smoking nine years later.
“We need to make sure cancer survivors, from the very beginning of diagnosis, have easier access to cessation interventions,” says Westmaas.
If you’d like to quit, the ACS offers the following advice:
- Use free hotlines (like 1-800-QUIT-NOW) to speak with trained counselors about quitting.
- Join a peer support group like Nicotine Anonymous.
- Enroll in a tobacco cessation class sponsored by the ACS, American Lung Association or your local health department.
- Tell your friends about your plans to quit.
- Spend time with non-smokers and ex-smokers who support your efforts.
- Make plans in smoke-free settings.
- Identify friends and family members who can be patient with your cravings and field late night or early morning phone calls.
For tips on helping a loved one quit smoking, consult
“Helping a Smoker Quit: Do’s and Don’ts,” by the ACS.
A Well-Known Enemy
In 1964, more than 40 percent of Americans regularly smoked cigarettes—possibly the highest smoking rate in U.S. history. That year, U.S. Surgeon General (and longtime smoker) Luther Terry released a report that would be credited with changing the smoking habits of the country. The report, the first of its kind, told the public that smoking causes lung cancer and other diseases. Based on thousands of studies, the report sparked a major public health initiative and paved the way for new government control over the sale and marketing of tobacco products. The following year, the U.S. Congress passed the first legislation requiring warning labels on cigarette packs.
The smoking rate has dropped significantly since 1964, though roughly 18 percent of American adults continue to smoke, according to data from 2013, the latest year for which statistics are available. In the 1980s, Congress enacted additional tobacco-related laws—including ones governing smokeless tobacco. The U.S. Food and Drug Administration (FDA) was given authority over tobacco products in 2009.
The tobacco controls that followed the 1964 Surgeon General’s report have saved the lives of about 8 million people who would have died prematurely from tobacco-related diseases, according to a study published Jan. 8, 2014, in the
Journal of the American Medical Association (JAMA). Despite that success, tobacco use continues to take a heavy toll. Overall, the ACS estimates that nearly 176,000 of more than 585,000 U.S. cancer deaths in 2014 can be blamed on tobacco use.
The vast majority of current tobacco users started young, and even with efforts to educate youth about the dangers of tobacco use, kids continue to light up. “Every kid at the end of elementary school can recite all the bad things that are due to smoking, but as soon as they hit middle school and see those ninth-graders smoking, all that stuff goes out the window,” says Peter Shields, a physician at the Ohio State University Comprehensive Cancer Center in Columbus who studies the impact of environmental factors, including tobacco use, on cancer risk. “We still have it in our culture that smoking is sexy and cool and rebellious.”
There is some good news: According to the CDC’s Youth Risk Behavior Surveillance System, cigarette smoking among high school students has decreased from about one in three in 1997 to about one in six in 2013. However, while rates of smokeless tobacco usage among high school students fluctuated during that time, today about one in 11 are using it—roughly the same rate as in 1997. The nonprofit Campaign for Tobacco-Free Kids attributes the attraction largely to expensive marketing efforts by tobacco companies, which include offering smokeless tobacco in a variety of flavors and youth-targeted advertising.
The key to keeping kids from developing tobacco habits is to de-normalize the habit, says Shields. As an example: Ohio State University in Columbus, where he works, adopted a 100 percent tobacco-free policy on Jan. 1, 2014. No one can use tobacco anywhere on campus. Similarly, many state and local governments have instituted bans on smoking in places like restaurants, public parks and beaches—and a 2011 Gallup poll suggests the majority of Americans support such bans.
The availability of support to help adults quit is also vital, especially for tobacco users who have already been diagnosed with cancer. According to a study published by Herbst and his colleagues in the April 15, 2013,
Clinical Cancer Research, evidence-based cessation strategies are often not included in patients’ cancer treatment plans or implemented according to established guidelines for treating tobacco use.
Researcher J. Lee Westmaas, the director of Tobacco Control Research in the Behavioral Research Center at the ACS, says physicians should routinely ask patients about their tobacco use and offer resources to help users quit. Some cancer centers and hospitals offer free tobacco cessation programs, and some even have cessation experts who can help create a personalized plan.
“We know that for [patients with] some cancers”—including lung, esophageal and head and neck—“quitting rates are initially quite high,” says Westmaas. “But there is a dropping off—probably [in part] because they’re not getting continuous follow-up and not being asked every time they see a health provider whether they’re still smoking or not.” Patients whose doctors don’t counsel them about how to quit can be proactive by asking for help every time they see a doctor, he says. There are plenty of options, from telephone helplines to hospital staff, which can help patients quit in the most effective way.
Whether they have ever used tobacco or not, people diagnosed with oral, lung, bladder and other tobacco-linked cancers often face a social stigma. Here’s how you can support your loved one, friend or colleague:
- Remember that many factors can contribute to a cancer diagnosis, and blaming people for their own disease may make it harder for them to cope, says researcher J. Lee Westmaas at the American Cancer Society.
- Think of nicotine addiction as a medical condition that can be treated, rather than a behavioral problem that should be judged, says Jyoti Patel, a thoracic oncologist at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago.
- Without being judgmental, help a friend or loved one who uses tobacco to research cessation tools, such as support groups and nicotine replacement therapies like patches, says thoracic oncologist Roy Herbst at Yale Cancer Center in New Haven, Connecticut. Quitting is the single best way for patients who use tobacco to improve their health. “No one leads a perfect life,” he says.
- A person may need help adjusting to the new reality of a cancer diagnosis. “Help them find all the information they need and help them with decisions,” says Susan Warmerdam, a lung cancer survivor. Most important, she says, “don’t give up on them.”
Staring Down the Stigma
Cancer patients need compassion and support from those around them, and those with tobacco-related diseases are no exception. Rita McCambridge, 54, started smoking as a teenager and quit when she was 30, after her mother-in-law died of small-cell lung cancer. “After watching her suffer, it didn’t take much for me to kick the smokes to the curb and never touch them again,” says the mother of three from La Grange, Illinois, who works in the human resources office of a software company. “I never wanted my children to have to go through that,” she says.
That feeling was reinforced 13 years later when McCambridge’s sister, Patricia Fortier, was diagnosed with non–small cell lung cancer. Then, a month before her sister’s death in February 2013, McCambridge was diagnosed with non–small cell lung cancer, too. The stage IV lung cancer had metastasized to her left hip, and McCambridge began a series of radiation and chemotherapy treatments that continue today.
McCambridge found the treatments to be unexpectedly brutal—she developed pneumonitis, an inflammation of the lungs, while on the chemotherapy drug Gemzar (gemcitabine) and had to switch therapies—but she also hadn’t counted on the stigma. During a routine colonoscopy, she mentioned her lung cancer diagnosis. “The first question the nurse asked was if I was a smoker. I was furious. My response was, ‘So if I was, does that mean I deserve to die?’ ” she recalls. The nurse apologized.
“What many people don’t realize is that over half of all people who are newly diagnosed with lung cancer either have never smoked or are former smokers, many of whom quit decades ago,” says McCambridge’s doctor, thoracic oncologist Jyoti Patel at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago. And even if they currently smoke, blaming them isn’t helpful. Patel says that a diagnosis of metastatic cancer can trigger feelings of guilt or shame in a patient and that additional criticism from others won’t speed the quitting process.
The stigma can even affect people who haven’t used tobacco. Susan Warmerdam, 50, an executive assistant in Chicago, was diagnosed with stage IV non–small cell lung cancer in February 2012.
“When I was first diagnosed and told people, I got ‘the looks’ and the ‘Did you smoke?’ comments from people, like I brought it on myself and should’ve known better,” says Warmerdam, who has never smoked. “I’d tell them anyone can get lung cancer—any age, any race, any gender, short, tall, thin, thick, people who are otherwise healthy. Suddenly they started caring and asking questions, because now it is something they could get, too.”
For 23 months, Warmerdam took Tarceva (erlotinib), a targeted drug prescribed to patients with advanced lung cancer who, like Warmerdam, have a mutation in the EGFR gene. She also had three surgeries. Though she likely still has cancer cells in her body, Warmerdam says, she currently has no evidence of disease.
According to Patel, who is also Warmerdam’s doctor, the stigma associated with tobacco-linked cancers doesn’t just hurt patients individually—it has translated into an inequality in research funding. “Lung cancer is funded at a pittance compared to breast cancer, primarily because of stigmatization, I think,” Patel says. “Also, there aren’t as many long-term survivors as with other cancers, so people can’t advocate for themselves.”
In 2013, the most recent year for which data are available, the National Cancer Institute (NCI) spent almost $286 million on lung cancer research, compared with nearly $560 million for breast cancer research. Those numbers translate to about $1,800 per lung cancer death, compared with approximately $14,000 per breast cancer death. More than half of the money dedicated to lung cancer went toward research on treatment, cancer biology or understanding causes. The rest included funding for prevention (11 percent); early detection, diagnosis and prognosis (12 percent); and survivorship and outcomes research (21 percent).
“I feel like we’ve missed a ton of opportunities” for better understanding how to curb lung cancer, Patel says. The number of lung cancer clinical trials—devoted to not only treatment, but also to screening and prevention—is “a fraction of those for other cancers.” The way to get more funding, she suggests, is to increase awareness of the disease and reduce its stigma among the public.
Patel thinks the outlook for lung cancer is improving with FDA control over nicotine delivery devices, which may help reduce the number of young people who become addicted to tobacco.
Giving the FDA control over tobacco represents a major shift, she says. “Recognizing that this is a medical issue and not only a behavioral issue will change the tenor of the conversation.”
Pulmonologist Norman H. Edelman, a senior consultant for scientific affairs for the American Lung Association in Chicago, calls the stigma associated with tobacco-related cancers “wholly inappropriate.” He points to the importance of understanding and overcoming addiction.
“Almost everybody who [smoked and] got lung cancer was addicted to cigarettes as a child or a teenager, by a voracious tobacco industry with effective promotions,” he says. “These people are not careless; they’re victims of very powerful addictive tactics by the industry, and they deserve the best care they can get,” which should include access to treatment for their disease as well as for their addiction.
Tobacco cessation aids like nicotine patches have been available since the 1980s, and for years, researchers have known that nicotine’s influence stems from its ability to trigger nicotinic acetylcholine receptors on cells in place of the body’s natural acetylcholine. The cessation drug Chantix (varenicline), which the FDA approved in 2006—and to which it later added a “black box” warning about potential serious neurological side effects like depression and suicidal behavior—binds to these receptors and is intended to help reduce the urge to use tobacco.
More recently, scientists have identified genetic variations in these receptors, which can influence nicotine dependence and smoking behavior. Not everyone is equally susceptible to addiction, and with a better understanding of the genetic underpinnings of nicotine sensitivity, researchers have begun to explore the use of tailored smoking cessation treatments and preventive strategies based on these genetic differences. Today, clinical trials are also underway looking at whether vaccines or existing drugs, like certain antidepressants, may help people kick the habit.
Shields, in Columbus, says in the past he found it very hard to understand why adults “who should know better” would continue to smoke, but his research on tobacco and addiction changed his outlook. “People [usually] start to smoke [or use chewing tobacco] when they’re young and think they’re immortal,” he says. “Think about those individuals who stand outside in 2-degree weather to smoke: Every smoker knows it’s bad for them.” And while some manage to quit on their own, others need help.
For some tobacco users, the inspiration to find help quitting comes from seeing a loved one, colleague or public figure suffer. At least three other Major League Baseball (MLB) players pledged to stop chewing tobacco in the wake of Gwynn’s death. And outgoing MLB Commissioner Bud Selig announced that he’d like to see the practice banned as part of future contract negotiations.
It’s one more effort that may dissuade kids from picking up the habit to be like their role models. And, down the line, it may keep them from becoming another addition to the number of cancer deaths from tobacco.
December 31, 2014