Updated Review of Major Cancer Risk Factors and Screening Test Use in the United States in 2018 and 2019, with a Focus on Smoking Cessation

Cancer prevention and early detection efforts are central to reducing cancer burden. Herein, we present estimates of cancer risk factors and screening tests in 2018 and 2019 among US adults, with a focus on smoking cessation. Cigarette smoking reached a historic low in 2019 (14.2%) partly because 61.7% (54.9 million) of all persons who had ever smoked had quit. Yet, the quit ratio was <45% among lower-income, uninsured, and Medicaid-insured persons, and was <55% among Black, American Indian/Alaska Native, lower-educated, lesbian, gay or bisexual, and recent immigrant persons, and in 12 of 17 Southern states. Obesity levels remain high (2017-2018: 42.4%) and were disproportionately higher among Black (56.9%) and Hispanic (43.7%) women. HPV vaccination in adolescents 13 to 17 years remains underutilized and over 40% were not up-to-date in 2019. Cancer screening prevalence was suboptimal in 2018 (colorectal cancer ≥50 years: 65.6%; breast ≥45 years: 63.2%; cervical 21-65 years: 83.7%), especially among uninsured adults (colorectal: 29.8%; breast: 31.1%). This snapshot of cancer prevention and early detection measures was mixed, and substantial racial/ethnic and socioeconomic disparities persisted. However, gains could be accelerated with targeted interventions to increase smoking cessation in under-resourced populations, stem the obesity epidemic, and improve screening and HPV vaccination coverage.

[Interventions for smoking cessation in 2018]

Smoking cessation treatments have been proved effective to stop smoking. For pharmacological treatments, nicotine replacement therapies (NRT) as well as bupropion allow to increase 6 month-abstinence rates by more than 80% in comparison with placebo while varenicline prescription doubles success rates in the same conditions. These results mean that for 10 smokers who quit with placebo, 18 are expected to quit with NRT or bupropion and 28 are expected to quit with varenicline. Varenicline is 50% more effective than nicotine patch and 70% more effective than nicotine gum. Nevertheless, a combination including NRT patch and oral nicotine forms is as effective as varenicline, thus leading to encourage the prescription of a combination NRT when NRT are chosen. For these three pharmacological treatments, cardiovascular as well as neuropsychiatric tolerance were not found statistically different from placebo in randomized controlled trials. Yet, bupropion prescription leads to an increasing risk of seizure (1/1000 to 1/1500). For behavioral treatment, motivational interviewing as well as cognitive behavior therapies are been proven to be effective to stop smoking but few smokers have access to this treatment. Smoking cessation mobile application and smartphone application seem to be promising in terms of effectiveness and might be useful to reach more smokers.

[The "modernization" of health education in both German states between 1949 and 1975. The example of smoking]

Using the example of smoking, this article scrutinizes the notions of order, educational conduct and images of subjects in the health education of both German states between 1949 and the mid 70s. Drawing on archival sources, publications and educational media from both health ministries, the Deutsches Hygiene-Museum and the Bundeszentrale für gesundheitliche Aufklärung I reconstruct the organizational, conceptual and medial shift of health education from "citizenship" to a technology of communication and public relation, needing "scientification" in the 1960s. New epidemiological evidence fostered the belief in an efficacious prevention of manly coded and with smoking associated cardio-vascular diseases by forming healthy behavior. This went hand in hand with the increase of state responsibility for the health of its citizens and the import of new knowledge stemming from social research and new methodological expertise from advertising. At the same time the ideal of a comprehensible citizen shifted into a "socialist personality" that was to be shaped by a hierarchical and consistent education in the German Democratic Republic. In the Federal Republic of Germany the general principle of the self-determined citizen unfolded the antagonism of health education between individual emancipation and imposition.

Health improvement in Poland is contingent on continued extensive tobacco control measures

Tobacco smoking is a major avoidable single cause of premature mortality in Poland. Almost one in three Polish males do not live to 65 years of age, and almost half of this premature mortality can be traced back to the much higher smoking prevalence in Poland than in Western Europe--every third Polish male and every fourth Polish female smokes daily. However, the current health situation in Poland is much better than two decades ago when the country entered a period of political and economic upheaval. In the early 1990s, the state of health of the Polish population was catastrophic and its tobacco consumption levels the highest in the world. In the early 1990s, the probability of a 15-year-old Polish boy living to the age of 60 was not just twice lower than in Western Europe, but also lower than in China or India. The health policy of limiting the health consequences of smoking conducted by the European Union and, in the last two decades, by the Polish parliament and government, helped to stop this health catastrophe. In Poland, cigarette consumption has decreased by 30% since 1990, as did lung cancer mortality among males. Despite this progress, tobacco smoking remains the most serious health problem in Poland. Therefore, comprehensive tobacco control policy should not only be continued, but expanded and accelerated. The EU Tobacco Products Directive proposes a package of actions for reducing tobacco-related health harm in Europe. The Directive proposal is rational, science-and-evidence based, and grounded on the best practice examples from other countries. Both the Polish tobacco control law and the WHO Framework Convention on Tobacco Control (FCTC), ratified by Poland in 2006, oblige our country to support tobacco control, including all the initiatives taken by the European Union.

Interventions to increase smoking cessation at the population level: how much progress has been made in the last two decades?

This paper reviews the literature on smoking cessation interventions, with a focus on the last 20 years (1991 to 2010). These two decades witnessed major development in a wide range of cessation interventions, from pharmacotherapy to tobacco price increases. It was expected that these interventions would work conjointly to increase the cessation rate on the population level. This paper examines population data from the USA, from 1991 to 2010, using the National Health Interview Surveys. Results indicate there is no consistent trend of increase in the population cessation rate over the last two decades. Various explanations are presented for this lack of improvement, and the key concept of impact = effectiveness × reach is critically examined. Finally, it suggests that the field of cessation has focused so much on developing and promoting interventions to improve smokers' odds of success that it has largely neglected to investigate how to get more smokers to try to quit and to try more frequently. Future research should examine whether increasing the rate of quit attempts would be key to improving the population cessation rate.

The regulation of nicotine in the United Kingdom: how nicotine gum came to be a medicine, but not a drug

This article explores the utility of actor-network theory (ANT) as a tool for socio-legal research. ANT is deployed in a study of the evolution of divided regulatory responsibility for tobacco and medicinal nicotine (MN) products in the United Kingdom, with a particular focus on how the latter came to be regulated as a medicine. We examine the regulatory decisions taken in the United Kingdom in respect of the first MN product: a nicotine-containing gum developed in Sweden, which became available in the United Kingdom in 1980 as a prescription-only medicine under the Medicines Act 1968. We propose that utilizing ANT to explore the development of nicotine gum and the regulatory decisions taken about it places these decisions into the wider context of ideas about tobacco control and addiction, and helps us to understand better how different material actors acted in different networks, leading to very different systems of regulation.

Explaining the unexpected success of the smoking ban in Italy: political strategy and transition to practice, 2000–2005

The approval (2003) and enforcement (2005) of a smoking ban in Italy have been viewed by many as an unexpectedly successful example of policy change. The present paper, by applying a processualist approach, concentrates on two policy cycles between 2000 and 2005. These had opposing outcomes: an incomplete decisional stage and an authoritative decision, enforced two years later. Through the analysis of the different phases of agenda setting, alternative specification and decision making, we have compared the quality of participation of policy entrepreneurs in the two cycles, their political strategies and, in these, the relevance of issue image. The case allows us to direct the attention of scholars and practitioners to an early phase of the policy implementation process – which we have named "transition to practice". This, managed with political strategy, might have strongly contributed to the final successful policy outcome.

From youth protection to individual responsibility: addressing smoking among young people in post-war West Germany

This article draws on health education material produced on smoking in the 1950s and 1960s in West Germany to question the extent to which smoking and health disappeared from the agenda in the post war decades, following the experience of anti-smoking propaganda during the Third Reich. It suggests that continuities can be seen in anti-smoking literature and campaigns both before and after the Third Reich around the notion of youth protection. In the early 1960s, there was a more decisive break with the past with the foundation of the Ministry of Health and a growing determination to make health education a federal responsibility. There was an evident shift towards notions of individual responsibility and rational choice, informed by a growing body of international epidemiological evidence on smoking and health. There were also some attempts to engage with youth culture in the 1960s, rather than seeing youth culture as a threat to the social order, as had been the case in older youth protection arguments against smoking.

Community pharmacists and tobacco in Great Britain: from selling cigarettes to smoking cessation services

AIMS

To illustrate the ways in which community pharmacists in Great Britain have been able to benefit from a close association with tobacco and smoking from its initial importation to the present time.

DESIGN

An analysis of relevant texts and documents, together with brief transcripts from an oral history investigation of community pharmacy in Great Britain.

SETTING

Community pharmacies in Great Britain during the 20th century.

PARTICIPANTS

Retired and practising community pharmacists with experience of the sale of tobacco products during the period.

MEASUREMENTS

Oral testimony of retired and practising community pharmacists about the use and sale of tobacco products, and quantitative analysis of commercially available products designed to help people stop smoking during the period.

FINDINGS

Community pharmacists have been involved continuously with the tobacco habit since its first introduction into Britain. During the course of the 20th century the emphasis shifted from the sale of tobacco products to the sale of medicines intended to help people to give up smoking. Smoking cessation initiatives continue to be an important part of the business of many pharmacies.

CONCLUSIONS

The paper illustrates the continuing tension that exists between pharmacy as business and pharmacy as profession. The sale of tobacco products and, more recently, products to help people give up smoking, has been a small but significant part of the business of many community pharmacists throughout the centuries.

[The history of antitobacco actions in the last 500 years. Part. II. Medical actions]

Tobacco was brought to Europe by Christopher Columbus, who discovered it in Cuba in October, 1492. Spread of tobacco consumption was initiated by the French diplomat Jean Nicot de Villemain, who in 1560 recommended it in the form of powdered tobacco leaves to the French Queen Catherine de Medice to combat her migraine headaches, and introduced the term Nicotiana tobaccum. Tobacco consumption greatly rose after the I World War, and after the II World War it became very common, especially among man. In the first half of the 20th century the sale of tobacco products rose by 61%, and cigarettes dominated the market of tobacco products. At the beginning of the 20th century cigarettes constituted only 2% of the total sale of tobacco products, while in the middle of the 20th century--more than 80%. Although the first epidemiological papers indicating that "smoking is connected with the shortening of life span" were published in the first half of the 20th century, not until 1950 did Hill and Doll in Great Britain, and Wynder and Graham in USA in 1951 show a statistically significant correlation between cigarettes smoking and lung cancer occurrence. Many controversies according the use of tobacco accompanied it from the beginning of its presence in Europe. The conflicting opinions according to its influence to health coexisted in the 16th to 19th centuries. In this period, especially in the 19th century dominated moral and religious arguments against tobacco. In the 20th century however, and particularly in its second part, development in medical research was enhanced by civil voluntary actions against advertisement and passive smoking. This lead to the significant limitation of tobacco expansion in Europe, USA and Canada in the end of the 20th century.

Lifestyle, health, and health promotion in Nazi Germany

Several health related behaviours came under scrutiny in the 1930s and '40s in Germany, but did the associated campaigns achieve any benefits?

Ask your doctor: the construction of smoking in advertising posters produced in 1946 and 2004

This paper examines two full-page A3 poster advertisements in mass magazines produced at two time points over a 60-year period depicting smoking and its effects, with particular relation to lung cancer. Each poster represents the social and cultural milieu of its time. The writings of Foucault are used to explore the disciplinary technologies of sign systems as depicted in the two posters. The relationships between government, tobacco companies and drug companies and the technologies of production are examined with regard to the development of smoking cessation strategies. The technologies of power are associated with the constructions of risk and lifestyles. The technologies of the self locate smokers as culpable subjects responsible for their individual health. Finally, the meshing of these technologies places the doctor in the frame as "authoritative knower" and representative of expert systems.

From rapid smoking to the Internet: five decades of cessation research

This review summarizes the author's smoking cessation research from the 1960s into the 21st century. Both contextual and personal factors that led the author to undertake cessation research and to move from intensive clinical interventions to brief, population-focused interventions, especially in healthcare settings, are described. Suggestions are offered as to how research can address the problem of inconsistent delivery of effective interventions in healthcare settings.

The silent epidemic: tobacco and the evolution of lung cancer and its treatment

Considered a rare disease during the 19th century, lung cancer became the most virulent and lethal cause of cancer mortality by the end of the 20th century. In this paper, lung cancer and its treatment are addressed within the social, cultural, economic, and political context of the last century. Because lung cancer is related to the consumption of cigarettes, the battles over tobacco control are highlighted. Four time periods are addressed: the early years (1900-1930), beginning of the epidemic (1930-1960), defining the problem (1960-1980), and expanding options (1980-1990s). Although improvements have been made in science and technology, attempts at finding curative treatments have met with little success. Smoking cessation and efforts to control tobacco (especially among children and adolescents) remain the most important factors if the incidence of lung cancer is to be curtailed in the future. Providing care to individuals with the illness is a current challenge. Research examining the efficacy of treatments and their effect on survival, health-related quality of life, and cost outcomes is essential and can be best achieved through the efforts of multidisciplinary teams.

Charles G. Pease, DDS, MD: anti-tobacco crusader and clean life advocate

Dr. Charles Giffin Pease, a colorful, feisty, New York City reformer practiced both dentistry and medicine and lectured in various dental and medical schools. At several New York dental institutions, he taught oral surgery, materia medica, therapeutics and pathology. From the age of 12 until his death (a 75 year span) Pease waged an unrelenting war against "everything that harms the human race." He wrote and lectured unceasingly railing against what he believed to be life damaging behaviors. These included: tobacco use; alcohol, coffee, tea and ginger ale consumption; corset wearing; vinegar, meat, cocoa, chocolate and condiment intake, and even the licking of artificially flavored lollipops. While he was adamantly opposed to all of these practices, he invested his strongest efforts campaigning against the manufacture, sale and use of tobacco products; and he emphatically supported clean living causes. His anti-tobacco stance was based chiefly on moral, ethical and religious precepts. Additionally, he expected community role models (public health officials, clergymen, physicians and dentists) to become involved in this vital health issue. When publicly presenting his cause, he used a moralistic, judgmental approach. Almost single handedly, Pease spear-headed legislation that prohibited smoking in subways, elevated trains, hotels and restaurants.

Smoking cessation treatments in Spain. A thirty-year perspective: 1966-1996

This paper examines the evolution of the scientific literature over the past thirty years (1966-1996) about smoking studies conducted in Spain and determines where the trend is leading. We utilized local (Indice Médico Español) and international databases (MedLine, PsycLit) to find papers related to the treatment of smoking in Spain from 1966 to 1996, including such approaches as medical advice, pharmacological, psychological, community, and combined approaches. The total number of articles about studies related to tobacco contained in the three databases in the 1966-1996 period was 1,026. The largest number of articles, a total of 455 (44.3%), was published between 1991 and 1996. Specifically, of the 125 articles about smoking cessation treatments, empirical studies constitute 48.8% (n = 61) of all the articles published. The results of the studies and the increasing number of publications indicate that in the present decade there has been intense interest from both health professionals and the Health Administration in promoting formal smoking treatment programs. Nevertheless, too few empirical studies about smoking cessation methods have been undertaken to date. It is still necessary to perform more studies with nicotine replacement therapy, behavior therapy, and combined therapy, as well as controlled studies of treating specific smoking populations, and community approaches.