1. Improving Smoking Cessation in Cancer Patients Graham Warren M.D., Ph.D. Department of Radiation Medicine Department of Pharmacology and Therapeutics Roswell Park Cancer Institute

2. Disclosure and Contact Information I have no financial disclosures or conflicts to report Starting February 18, my contact information will change to the following Graham Warren M.D., Ph.D. Associate Professor Vice Chairman for Radiation Oncology Department of Radiation Oncology Department of Cell and Molecular Pharmacology and Experimental Therapeutics Hollings Cancer Center Medical University of South Carolina, Charleston, SC warrengw@musc.edu

3. Cigarette Smoke Largest single contributor to cancer risk –Shifting views on largest contribution to preventable health risks as compared with obesity Over 7000 constituents in cigarette smoke –60+ known carcinogens Aldehydes Benzene Metals (cadmium, nickel, polonium) Nicotine Nitrosamines Polyaromatic hydrocarbons Large number of additives –Enhance absorption –Increase flavor –Increase addiction

4. Additives to Cigarettes (~600) Acetanisole Acetic Acid Acetoin Acetophenone 6-Acetoxydihydrotheaspirane 2-Acetyl-3- Ethylpyrazine 2-Acetyl-5-Methylfuran Acetylpyrazine 2-Acetylpyridine 3-Acetylpyridine 2-Acetylthiazole Aconitic Acid dl-Alanine Alfalfa Extract Allspice Extract,Oleoresin, and Oil Allyl Hexanoate Allyl Ionone Almond Bitter Oil Ambergris Tincture Ammonia Ammonium Bicarbonate Ammonium Hydroxide Here are the first 65 (alphabetical order) Ammonium Phosphate Dibasic Ammonium Sulfide Amyl Alcohol Amyl Butyrate Amyl Formate Amyl Octanoate alpha-Amylcinnamaldehyde Amyris Oil trans-Anethole Angelica Root Extract, Oil and Seed Oil Anise Anise Star, Extract and Oils Anisyl Acetate Anisyl Alcohol Anisyl Formate Anisyl Phenylacetate Apple Juice Concentrate, Extract, and Skins Apricot Extract and Juice Concentrate 1-Arginine Asafetida Fluid Extract And Oil Ascorbic Acid 1-Asparagine Monohydrate 1-Aspartic Acid Balsam Peru and Oil Basil Oil Bay Leaf, Oil and Sweet Oil Beeswax White Beet Juice Concentrate Benzaldehyde Benzaldehyde Glyceryl Acetal Benzoic Acid, Benzoin Benzoin Resin Benzophenone Benzyl Alcohol Benzyl Benzoate Benzyl Butyrate Benzyl Cinnamate Benzyl Propionate Benzyl Salicylate Bergamot Oil Bisabolene Black Currant Buds Absolute Borneol

5. Additives to Cigarettes (~600) Acetanisole, Acetic Acid, Acetoin, Acetophenone, 6-Acetoxydihydrotheaspirane, 2-Acetyl-3- Ethylpyrazine, 2-Acetyl-5-Methylfuran, Acetylpyrazine, 2-Acetylpyridine, 3-Acetylpyridine, 2-Acetylthiazole, Aconitic Acid, dl-Alanine, Alfalfa Extract, Allspice Extract,Oleoresin, and Oil, Allyl Hexanoate, Allyl Ionone, Almond Bitter Oil, Ambergris Tincture, Ammonia, Ammonium Bicarbonate, Ammonium Hydroxide, Ammonium Phosphate Dibasic, Ammonium Sulfide, Amyl Alcohol, Amyl Butyrate, Amyl Formate, Amyl Octanoate, alpha-Amylcinnamaldehyde, Amyris Oil, trans-Anethole, Angelica Root Extract, Oil and Seed Oil, Anise, Anise Star, Extract and Oils, Anisyl Acetate, Anisyl Alcohol, Anisyl Formate, Anisyl Phenylacetate, Apple Juice Concentrate, Extract, and Skins, Apricot Extract and Juice Concentrate, 1-Arginine, Asafetida Fluid Extract And Oil, Ascorbic Acid, 1-Asparagine Monohydrate, 1-Aspartic Acid, Balsam Peru and Oil, Basil Oil, Bay Leaf, Oil and Sweet Oil, Beeswax White, Beet Juice Concentrate, Benzaldehyde, Benzaldehyde Glyceryl Acetal, Benzoic Acid, Benzoin, Benzoin Resin, Benzophenone, Benzyl Alcohol, Benzyl Benzoate, Benzyl Butyrate, Benzyl Cinnamate, Benzyl Propionate, Benzyl Salicylate, Bergamot Oil, Bisabolene, Black Currant Buds Absolute, Borneol, Bornyl Acetate, Buchu Leaf Oil, 1,3-Butanediol, 2,3-Butanedione, 1-Butanol, 2-Butanone, 4(2-Butenylidene)-3,5,5-Trimethyl-2-Cyclohexen-1-One, Butter, Butter Esters, and Butter Oil, Butyl Acetate, Butyl Butyrate, Butyl Butyryl Lactate, Butyl Isovalerate, Butyl Phenylacetate, Butyl Undecylenate, 3-Butylidenephthalide, Butyric Acid], Cadinene, Caffeine, Calcium Carbonate, Camphene, Cananga Oil, Capsicum Oleoresin, Caramel Color, Caraway Oil, Carbon Dioxide, Cardamom Oleoresin, Extract, Seed Oil, and Powder, Carob Bean and Extract, beta-Carotene, Carrot Oil, Carvacrol, 4-Carvomenthenol, 1-Carvone, beta-Caryophyllene, beta-Caryophyllene Oxide, Cascarilla Oil and Bark Extract, Cassia Bark Oil, Cassie Absolute and Oil, Castoreum Extract, Tincture and Absolute, Cedar Leaf Oil, Cedarwood Oil Terpenes and Virginiana, Cedrol, Celery Seed Extract, Solid, Oil, And Oleoresin, Cellulose Fiber, Chamomile Flower Oil And Extract, Chicory Extract, Chocolate, Cinnamaldehyde, Cinnamic Acid, Cinnamon Leaf Oil, Bark Oil, and Extract, Cinnamyl Acetate, Cinnamyl Alcohol, Cinnamyl Cinnamate, Cinnamyl Isovalerate, Cinnamyl Propionate, Citral, Citric Acid, Citronella Oil, dl-Citronellol, Citronellyl Butyrate, itronellyl Isobutyrate, Civet Absolute, Clary Oil, Clover Tops, Red Solid Extract, Cocoa, Cocoa Shells, Extract, Distillate And Powder, Coconut Oil, Coffee, Cognac White and Green Oil, Copaiba Oil, Coriander, Extract and Oil, Corn Oil, Corn Silk, Costus Root Oil, Cubeb Oil, Cuminaldehyde, para-Cymene, 1-Cysteine, Dandelion Root Solid Extract, Davana Oil, 2-trans, 4-trans-Decadienal, delta-Decalactone, gamma-Decalactone, Decanal, Decanoic Acid, 1-Decanol, 2-Decenal, Dehydromenthofurolactone, Diethyl Malonate, Diethyl Sebacate, 2,3-Diethylpyrazine, Dihydro Anethole, 5,7-Dihydro-2-Methylthieno(3,4-D) Pyrimidine, Dill Seed Oil and Extract, meta-Dimethoxybenzene, para-Dimethoxybenzene, 2,6-Dimethoxyphenol, Dimethyl Succinate, 3,4-Dimethyl-1,2 Cyclopentanedione, 3,5- Dimethyl-1,2-Cyclopentanedione, 3,7-Dimethyl-1,3,6-Octatriene, 4,5-Dimethyl-3-Hydroxy-2,5-Dihydrofuran-2-One, 6,10-Dimethyl-5,9-Undecadien-2-One, 3,7-Dimethyl-6-Octenoic Acid, 2,4 Dimethylacetophenone, alpha,para- Dimethylbenzyl Alcohol, alpha,alpha-Dimethylphenethyl Acetate, alpha,alpha Dimethylphenethyl Butyrate, 2,3-Dimethylpyrazine, 2,5-Dimethylpyrazine, 2,6-Dimethylpyrazine, Dimethyltetrahydrobenzofuranone, delta-Dodecalactone, gamma-Dodecalactone, para-Ethoxybenzaldehyde, Ethyl 10-Undecenoate, Ethyl 2-Methylbutyrate, Ethyl Acetate, Ethyl Acetoacetate, Ethyl Alcohol, Ethyl Benzoate, Ethyl Butyrate, Ethyl Cinnamate, Ethyl Decanoate, Ethyl Fenchol, Ethyl Furoate, Ethyl Heptanoate, Ethyl Hexanoate, Ethyl Isovalerate, Ethyl Lactate, Ethyl Laurate, Ethyl Levulinate, Ethyl Maltol, Ethyl Methyl Phenylglycidate, Ethyl Myristate, Ethyl Nonanoate, Ethyl Octadecanoate, Ethyl Octanoate, Ethyl Oleate, Ethyl Palmitate, Ethyl Phenylacetate, Ethyl Propionate, Ethyl Salicylate, Ethyl trans-2-Butenoate, Ethyl Valerate, Ethyl Vanillin, 2-Ethyl (or Methyl)-(3,5 and 6)-Methoxypyrazine, 2-Ethyl-1-Hexanol, 3-Ethyl -2 -Hydroxy-2-Cyclopenten-1-One, 2-Ethyl-3, (5 or 6)-Dimethylpyrazine, 5-Ethyl-3-Hydroxy-4- Methyl-2(5H)-Furanone, 2-Ethyl-3-Methylpyrazine, 4-Ethylbenzaldehyde, 4-Ethylguaiacol, para-Ethylphenol, 3-Ethylpyridine, Eucalyptol, Farnesol, D-Fenchone, Fennel Sweet Oil, Fenugreek, Extract, Resin, and Absolute, Fig Juice Concentrate, Food Starch Modified, Furfuryl Mercaptan, 4-(2-Furyl)-3-Buten-2-One, Galbanum Oil, Genet Absolute, Gentian Root Extract, Geraniol, Geranium Rose Oil, Geranyl Acetate, Geranyl Butyrate, Geranyl Formate, Geranyl Isovalerate, Geranyl Phenylacetate, Ginger Oil and Oleoresin, 1-Glutamic Acid, 1-Glutamine, Glycerol, Glycyrrhizin Ammoniated, Grape Juice Concentrate, Guaiac Wood Oil, Guaiacol, Guar Gum, 2,4-Heptadienal, gamma-Heptalactone, Heptanoic Acid, 2-Heptanone, 3-Hepten-2-One, 2-Hepten-4- One, 4-Heptenal, trans -2-Heptenal, Heptyl Acetate, omega-6-Hexadecenlactone, gamma-Hexalactone, Hexanal, Hexanoic Acid, 2-Hexen-1-Ol, 3-Hexen-1-Ol, cis-3-Hexen-1-Yl Acetate, 2-Hexenal, 3-Hexenoic Acid, trans-2-Hexenoic Acid, cis-3-Hexenyl Formate, Hexyl 2-Methylbutyrate, Hexyl Acetate, Hexyl Alcohol, Hexyl Phenylacetate, 1-Histidine, Honey, Hops Oil, Hydrolyzed Milk Solids, Hydrolyzed Plant Proteins, 5-Hydroxy-2,4-Decadienoic Acid delta- Lactone, 4-Hydroxy-2,5-Dimethyl-3(2H)- Furanone, 2-Hydroxy-3,5,5-Trimethyl-2-Cyclohexen-1-One, 4-Hydroxy -3-Pentenoic Acid Lactone, 2-Hydroxy-4-Methylbenzaldehyde, 4-Hydroxybutanoic Acid Lactone, Hydroxycitronellal, 6-Hydroxydihydrotheaspirane, 4-(para-Hydroxyphenyl)-2-Butanone, Hyssop Oil, Immortelle Absolute and Extract, alpha-Ionone, beta-Ionone, alpha-Irone, Isoamyl Acetate, Isoamyl Benzoate, Isoamyl Butyrate, Isoamyl Cinnamate, Isoamyl Formate, Isoamyl Hexanoate, Isoamyl Isovalerate, Isoamyl Octanoate, Isoamyl Phenylacetate, Isobornyl Acetate, Isobutyl Acetate, Isobutyl Alcohol, Isobutyl Cinnamate, Isobutyl Phenylacetate, Isobutyl Salicylate, 2-Isobutyl-3-Methoxypyrazine, alpha-Isobutylphenethyl Alcohol, Isobutyraldehyde, Isobutyric Acid, d,l-Isoleucine, alpha- Isomethylionone, 2-Isopropylphenol, Isovaleric Acid, Jasmine Absolute, Concrete and Oil, Kola Nut Extract, Labdanum Absolute and Oleoresin, Lactic Acid, Lauric Acid, Lauric Aldehyde, Lavandin Oil, Lavender Oil, Lemon Oil and Extract, Lemongrass Oil, 1-Leucine, Levulinic Acid, Licorice Root, Fluid, Extract and Powder, Lime Oil, Linalool, Linalool Oxide, Linalyl Acetate, Linden Flowers, Lovage Oil And Extract, 1-Lysine], Mace Powder, Extract and Oil, Magnesium Carbonate, Malic Acid, Malt and Malt Extract, Maltodextrin, Maltol, Maltyl Isobutyrate, Mandarin Oil, Maple Syrup and Concentrate, Mate Leaf, Absolute and Oil, para-Mentha-8-Thiol-3-One, Menthol, Menthone, Menthyl Acetate, dl-Methionine, Methoprene, 2-Methoxy-4-Methylphenol, 2- Methoxy-4-Vinylphenol, para-Methoxybenzaldehyde, 1-(para-Methoxyphenyl)-1-Penten-3-One, 4-(para-Methoxyphenyl)-2-Butanone, 1-(para-Methoxyphenyl)-2-Propanone, Methoxypyrazine, Methyl 2-Furoate, Methyl 2-Octynoate, Methyl 2-Pyrrolyl Ketone, Methyl Anisate, Methyl Anthranilate, Methyl Benzoate, Methyl Cinnamate, Methyl Dihydrojasmonate, Methyl Ester of Rosin, Partially Hydrogenated, Methyl Isovalerate, Methyl Linoleate (48%), Methyl Linolenate (52%) Mixture, Methyl Naphthyl Ketone, Methyl Nicotinate, Methyl Phenylacetate, Methyl Salicylate, Methyl Sulfide, 3-Methyl-1-Cyclopentadecanone, 4-Methyl-1-Phenyl-2-Pentanone, 5-Methyl-2-Phenyl-2-Hexenal, 5-Methyl-2-Thiophenecarboxaldehyde, 6-Methyl-3,-5-Heptadien-2-One, 2-Methyl- 3-(para-Isopropylphenyl) Propionaldehyde, 5-Methyl-3-Hexen-2-One, 1-Methyl-3Methoxy-4-Isopropylbenzene, 4-Methyl-3-Pentene-2-One, 2-Methyl-4-Phenylbutyraldehyde, 6-Methyl-5-Hepten-2-One, 4-Methyl-5-Thiazoleethanol, 4-Methyl-5-Vinylthiazole, Methyl-alpha-Ionone, Methyl-trans-2-Butenoic Acid, 4-Methylacetophenone, para-Methylanisole, alpha-Methylbenzyl Acetate, alpha-Methylbenzyl Alcohol, 2-Methylbutyraldehyde, 3-Methylbutyraldehyde, 2-Methylbutyric Acid, alpha-Methylcinnamaldehyde, Methylcyclopentenolone, 2-Methylheptanoic Acid, 2-Methylhexanoic Acid, 3-Methylpentanoic Acid, 4-Methylpentanoic Acid, 2-Methylpyrazine, 5-Methylquinoxaline, 2-Methyltetrahydrofuran-3-One, (Methylthio)Methylpyrazine (Mixture Of Isomers), 3- Methylthiopropionaldehyde, Methyl 3-Methylthiopropionate, 2-Methylvaleric Acid, Mimosa Absolute and Extract, Molasses Extract and Tincture, Mountain Maple Solid Extract, Mullein Flowers, Myristaldehyde, Myristic Acid, Myrrh Oil, beta-Napthyl Ethyl Ether, Nerol, Neroli Bigarde Oil, Nerolidol, Nona-2-trans,6-cis-Dienal, 2,6-Nonadien-1-Ol, gamma-Nonalactone, Nonanal, Nonanoic Acid, Nonanone, trans-2-Nonen-1-Ol, 2-Nonenal, Nonyl Acetate, Nutmeg Powder and Oil, Oak Chips Extract and Oil, Oak Moss Absolute, 9,12-Octadecadienoic Acid (48%) And 9,12,15-Octadecatrienoic Acid (52%), delta-Octalactone, gamma-Octalactone, Octanal, Octanoic Acid, 1-Octanol, 2-Octanone, 3-Octen-2-One, 1-Octen-3-Ol, 1-Octen-3-Yl Acetate, 2-Octenal, Octyl Isobutyrate, Oleic Acid, Olibanum Oil, Opoponax Oil And Gum, Orange Blossoms Water, Absolute, and Leaf Absolute, Orange Oil and Extract, Origanum Oil, Orris Concrete Oil and Root Extract, Palmarosa Oil, Palmitic Acid, Parsley Seed Oil, Patchouli Oil, omega-Pentadecalactone, 2,3-Pentanedione, 2-Pentanone, 4-Pentenoic Acid, 2-Pentylpyridine, Pepper Oil, Black And White, Peppermint Oil, Peruvian (Bois De Rose) Oil, Petitgrain Absolute, Mandarin Oil and Terpeneless Oil, alpha-Phellandrene, 2- Phenenthyl Acetate, Phenenthyl Alcohol, Phenethyl Butyrate, Phenethyl Cinnamate, Phenethyl Isobutyrate, Phenethyl Isovalerate, Phenethyl Phenylacetate, Phenethyl Salicylate, 1-Phenyl-1-Propanol, 3-Phenyl-1-Propanol, 2-Phenyl-2-Butenal, 4-Phenyl-3- Buten-2-Ol, 4-Phenyl-3-Buten-2-One, Phenylacetaldehyde, Phenylacetic Acid, 1-Phenylalanine, 3-Phenylpropionaldehyde, 3-Phenylpropionic Acid, 3-Phenylpropyl Acetate, 3-Phenylpropyl Cinnamate, 2-(3-Phenylpropyl)Tetrahydrofuran, Phosphoric Acid, Pimenta Leaf Oil, Pine Needle Oil, Pine Oil, Scotch, Pineapple Juice Concentrate, alpha-Pinene, beta-Pinene, D-Piperitone, Piperonal, Pipsissewa Leaf Extract, Plum Juice, Potassium Sorbate, 1-Proline, Propenylguaethol, Propionic Acid, Propyl Acetate, Propyl para-Hydroxybenzoate, Propylene Glycol, 3-Propylidenephthalide, Prune Juice and Concentrate, Pyridine, Pyroligneous Acid And Extract, Pyrrole, Pyruvic Acid, Raisin Juice Concentrate, Rhodinol, Rose Absolute and Oil, Rosemary Oil, Rum, Rum Ether, Rye Extract, Sage, Sage Oil, and Sage Oleoresin, Salicylaldehyde, Sandalwood Oil, Yellow, Sclareolide, Skatole, Smoke Flavor, Snakeroot Oil, Sodium Acetate, Sodium Benzoate, Sodium Bicarbonate, Sodium Carbonate, Sodium Chloride, Sodium Citrate, Sodium Hydroxide, Solanone, Spearmint Oil, Styrax Extract, Gum and Oil, Sucrose Octaacetate, Sugar Alcohols, Sugars, Tagetes Oil, Tannic Acid, Tartaric Acid, Tea Leaf and Absolute, alpha-Terpineol, Terpinolene, Terpinyl Acetate, 5,6,7,8- Tetrahydroquinoxaline, 1,5,5,9-Tetramethyl-13-Oxatricyclo(8.3.0.0(4,9))Tridecane, 2,3,4,5, and 3,4,5,6-Tetramethylethyl-Cyclohexanone, 2,3,5,6-Tetramethylpyrazine, Thiamine Hydrochloride, Thiazole, 1-Threonine, Thyme Oil, White and Red, Thymol, Tobacco Extracts, Tochopherols (mixed), Tolu Balsam Gum and Extract, Tolualdehydes, para-Tolyl 3-Methylbutyrate, para-Tolyl Acetaldehyde, para-Tolyl Acetate, para-Tolyl Isobutyrate, para-Tolyl Phenylacetate, Triacetin, 2-Tridecanone, 2-Tridecenal, Triethyl Citrate, 3,5,5-Trimethyl -1-Hexanol, para,alpha,alpha-Trimethylbenzyl Alcohol, 4-(2,6,6-Trimethylcyclohex-1-Enyl)But-2-En-4-One, 2,6,6-Trimethylcyclohex-2-Ene-1,4-Dione, 2,6,6-Trimethylcyclohexa-1,3-Dienyl Methan, 4-(2,6,6-Trimethylcyclohexa- 1,3-Dienyl)But-2-En-4-One, 2,2,6-Trimethylcyclohexanone, 2,3,5-Trimethylpyrazine, 1-Tyrosine, delta-Undercalactone, gamma-Undecalactone, Undecanal, 2-Undecanone, 1, 0-Undecenal, Urea, Valencene, Valeraldehyde,Valerian Root Extract, Oil and Powder, Valeric Acid, gamma-Valerolactone, Valine, Vanilla Extract And Oleoresin, Vanillin, Veratraldehyde, Vetiver Oil, Vinegar, Violet Leaf Absolute, Walnut Hull Extract, Water, Wheat Extract And Flour, Wild Cherry Bark Extract, Wine and Wine Sherry, Xanthan Gum, 3,4-Xylenol, Yeast

6. Per Capita Consumption of Different Forms of Tobacco in the US, 1880–1995 US Department of Agriculture, 1996 14 18801890190019101920193019401950196019701980 Year 12 10 8 6 4 2 0 1990 Cigarettes Snuff Chewing Tobacco Pipe/Roll- your-own Cigars Per Capita Consumption

7. Annual Costs of Smoking www.cdc.gov/tobacco/data_statistics/Factsheets Total tobacco sales –$88,000,000,000 –Cost per pack: $4.26 Health related costs –$167,000,000,000 –Cost per pack: $7.18 KY and NC account for 2/3 of tobacco grown

8. Environmental Tobacco Smoke Exposure and Lung Cancer Risk Hackshaw AK et al. (1997) BMJ 315: 980 Review of 37 studies of women and 9 studies of men –All non-smokers with smoking spouse –478,000 women and 118,000 men –Overall 24% increase in lung cancer risk in women –Overall 35% increase in lung cancer risk in men Relative Risk of Lung Cancer

9. Lung Cancer Death Rates US Department of Agriculture, 1996 Year

10. Habits Start Early US Department of Agriculture, 1996 Year

11. Smoking and Head/Neck Cancer Treatment Browman GP et al. (1993) N Engl J Med 328: 159 115 Stage III-IV SCCA of H/N treated with XRT +/- fluorouracil 41% decrease in 2-year OS in patients who smoked during XRT –No difference based upon fluorouracil vs. placebo –No difference in toxicity (smokers during XRT vs. nonsmokers)

12. Smoking and Lung Cancer Treatment TRIBUTE trial of Erlotinib (Tarceva, EFGR TK inhibitor) –1,059 Stage IIIB-IV NSCLC patients –Patients randomized to carboplatin paclitaxel followed by Tarceva vs. placebo Overall analysis demonstrated no benefit over placebo Herbst RS et al. (2005) J Clin Oncol 23: 5892

13. Smoking and Lung Cancer Treatment Never smokers were analyzed for survival 1 –72 treated with Tarceva and 44 with placebo Tarceva with significant improvement in survival and time to progression Iressa (gefitinib) with improved survival in never-smokers with NSLC refractory to chemo 2 –8.9 vs. 6.1 months 1. Herbst RS et al. (2005) J Clin Oncol 23: 5892 2. Thatcher N et al. (2005) Lancet 366: 1527

14. Lung and Head/Neck Outcomes StudyPopulationOutcome (Smokers) Rades IJROBP 71: 1134, 2008NSCLC, 181 pts, RT +/- chemoDecreased LRC Tammemagi Chest 125: 27, 2004Lung, 1155 pts.Decreased survival Hinds J Nat Ca Inst 68: 395, 1982Lung, 223 womenDecreased 1-yr survival Johnston-Early JAMA 244: 2175, 1980SCLC, 112 pts, chemo +/- RTDecreased survival Stevens Arch Oto 109: 746, 1983H/N, 269 pts.Inc recurrence (75% less), dec survival Rugg Br J Radiol 63: 554, 1990H/N, 41 CHART pts.Increased mucositis Risch Am J Epidem 138: 281, 1993Lung, 845 pts.Women sm with higher risk vs. male sm Phillips Cancer 56: 2789, 1985Smokers, lung, 68 pts.Decreased NK activity Garces Chest 126: 1733, 2004NSCLC, 1506 pts.Decreased QOL Pytinia J Clin Oncol 22: 3981, 2004H/N, 100 pts.Decreased OS, RFS, DFS Marin Plast Recon Surg 121: 451, 2008H/N, 89 pts, flap reconPoor would healing (cor with cotinine) Videtic J Clin Oncol 21: 1544, 2003SCLC, 189 pts., chemo/RTDecreased MS and 5-yr OS Marshak IJROBP 43: 1009, 1999Glottic larynx, 207 pts., RTDecreased LRC (UV) Fox Lung Cancer 44: 237, 2004NSCLC, 237 pts, RT +/- chemoDecreased MS and 2-yr survival (early stg)

15. Gastrointestinal Outcomes StudyPopulationOutcome (Smokers) Richards Ann Surg 254:83 2011423 rectalC/F decrease CSS and OS, near decreased postop outcomes (p=0.09) Phipps Cancer 117:4948, 20112264 CRC with follow-up 6.9 months after diagnosis Current increase CSM (HR 1.3) and OM (HR 1.51) Weaver CEBP 20: 239, 2011743 CRC caregiversPoor mental health in caregivers of cancer patients who smoke Hawkes Eur J Cancer 47:267, 20101966 CRC survivors interviewed 5, 12, 24, 36, mo post diagnosis Current increase DM (HR 3.11) and cholesterol (HR 4.07) Roxburgh Ann Surg Oncol 2011 Richards Br J Cancer 103: 1356, 2010 302/320 CRC in surgical unitC/F decrease OS (p=0.07), increase CCI, infection, inflam, cardiac risk McCLeary Cancer 116: 957, 20101246 Stage III Colon 5FU+/- irinotecan (CALGB 89803) Current decrease OS (HR 1.67) Zingg Ann Surg Oncol 18:1460, 2011858 esophagectomy ptsIncreased pulm morbidity and pneumonia Kelly J Gastrointest Surg 15:250, 20102322 dist pancreatectomyIncreased Sx morbidity (MV) Kountourakis Cancer 117:925, 201149 T2N0 esoph pts (MDACC)Decreased DFS and OS (UV, MV) Shitara Cancer Sci 101:1001, 2010364 SCC esophdecrease survival (HR 2.43) esp. CRT Cooke Ann Thorac Surg 88:177, 20091133 esophagectomyIncreased anastamotic leakage Van der Heide Liver Transp 15:648, 2009401 liver transplant pts10-yr malig 13% active vs. 2% non-smok Wright J Thorac Cardiovasc Surg 137:587, 2009 2315 esophagectomies from 73 centers Increased major morbidity (leak, pmeumonia, bleeding, vent, death) Camargo Acta Gast Lat 37:238, 2007264 precancerous w. H. PyloriDecreased H. pylori eradication

16. Genitourinary (non-prostate) Outcomes StudyPopulationOutcome (Smokers) Park J Clin Oncol 24:5017, 2006901879 males (Korean Natl Health Insurance Corp) Current increase overall mortality in entire cohort Lammers Eur Urol 60:713, 2011718 NMIBC with epirubicinIncreased recurrence (UV, MV) Boström BJU Int 2011564 bladder, rad cyctectomyDecreased 10-yr DSS and OS Fleshner Cancer 86: 2337268 transitional cell CACurrent decrease RFS Yu Cancer Detect Prev 21:497, 199725436 tumor registry pts (MSK)Ever decrease OS Kroeger Cancer 2011802 RCCEver increase DSM, OM Richey Ann Oncol 22:1048, 2010188 metastatic RCC, targeted txCurrent decrease survival (UV, MV) Oh Urology 55:31, 2000148 RCCEver decrease OS in metastatic pts Van den Belt-Dusebout J Clin Oncol 25:4370, 2007 2707 testicular cancer survivorsIncreased second malignancy (HR 1.8) and heart disease (HR 1.8), both (HR 3.4) Shinn Urology 69:748, 2007162 testicular cancerIncreased depressive symptoms Van den Belt-Dusebout J Clin Oncol 24:467, 2006 2512 testicular 5 yr survivorsIncreased myocardial infarction (HR 2.6) Peat Plast Reconstr Surg 93:980, 1994180 limb sarcomaIncreased wound complications (UV) Hemmati Eur J Card Surg 40:328, 201179 chest wall resectionDecreased survival Newcomer J Surg Oncol 103:85, 201177 thigh sarcomaIncreased all cause mortality

17. Prostate Outcomes StudyPopulationOutcome (Smokers) Alsadius Radiother Oncol, 2011834 prostate, tx with RTIncreased urgency, cramps, diarrhea Kenfield JAMA 305:2548, 2011Prospective 5366 prostate (Health Prof Follow-up Study) Current increased overall, prostate, CVD mortality, reversed with 10+ yr cessation Joshu JNCI 103:835, 20111416 prostatectomyCurrent increase recurrence, cess by 1 yr post diagnosis with no increased risk Chen J Chin Med Assoc 74:69, 201189 radiation enterocolitis ptsIncreased need for surgery Taira IJROBP 79:1336, 20111656 RT/brachy pts +/ADTDecrease OS (HR 2.9 curr, 1.4 former) Ku Can Urol Assoc J 3:445, 2009213 prostatectomyDecreased QOL Weinmann Ca Caus Cont 21:117, 2010768 who died of prostate CA (Pros Ca Scr Mort Study) Most recent smoking status most important predictor for prostate cancer death Watters CEBP 18:2427, 2009283312 menIncreased fatal prostate cancer (HR 1.7) Huncharek Am J Pub Hth 100:693, 201024 cohort reviewIncreased prostate cancer and fatal PC Shiels Ca Caus Cont 20:877, 20091275 non-cancer (NHANES III)Increased serum+free testosterone Simone J Urol 180:2447, 20085070 prostatectom (CaPSURE)Increase non-prostate mortality Bittner IJROBP 72:433, 20081354 brachy +/- ADTIncreased CVD and non-prostate mort Boorjian J Urol 177:883, 20079780 prostate (CaPSURE)Increased bladder CA esp. current sm+RT Carlos J Am Coll Surg 200:216, 200522094 non-cancer menDecreased CRC and prostate screening

18. Gynecologic Outcomes StudyPopulationOutcome (Smokers) Kasuya Anticancer Res 31:3527, 2011228 cervix/uterine, postop RTIncreased enterocolitis Matsumoto Cancer Sci 101:2065, 2010516 LG SIL followed for 2 yrsDec regression, inc persistent HPV Jang J Cancer Surv 5:115, 20111920 br, CRC, Uterine survivorsIncreased stroke, decreased activity+QOL Ngô Gynecol Oncol 123:248, 2011257 IB1-IIV cerv, preop brachyDecreased 5-yr OS and DFS Girianelli Int J Gyn Obst 107:228, 20091236 LG SIL, followed for 3 yrsIncreased progression to CIN2+ Khan J Obst Gyn 29:123, 200980 VIN3Increased multicentric and persitent dz Coker Gynecol Oncol 112:365, 20092661 cervicalIncreased CSM Simen Scand J Infect Dis 40:745, 2008191 HPV infected womenDecreased antibodies to HPV 16/18 Ohno IJROBP 69:740, 20072167 cervical treated with RTIncreased second malignancy Waggoner Gynecol Oncol 103:853, 2006316 St IIB-IVA cervical, CRT (GOG 165) Decreased OS and PFS Self-reported and cotinine validated Modesitt Gynecol Oncol 103:300, 20063563 endometrialDecreased survival Wright Gynecol Oncol 98:84, 2005255 IB-IIB cervical, prospectiveIncrease recurrence, CSM, OM Eifel J Clin Oncol 20: 3651, 20023489 I-II cervical with RTIncreased bladder-bowel complication Hsia Prev Med 31:261, 200055278 WHI non cancer womenDecreased mam/pap/FS screening Maucort Int J Cancer 126:684, 20102408 womenPersistant HPV infection Schlumbrecht Cancer 117:3741, 2011194 low gr serous ovarianDecrease OS and RFS Kjaerbye CEBP 15:798, 2006295 St III ovarian (MALOVA)Increased mortality, improved with cess

19. Breast Outcomes StudyPopulationOutcome (Smokers) Angarita J Hosp Infect 79:328, 2011199 breast cancerIncreased postop infection Zaman Ann Oncol 2011261 tam/let breast (BIG 1-98)Decreased bone mineral density Land Ca Prev Res 4:1393, 2011NSABP P-1 (prevention)Decreased adherence to tamoxifen Hellmann Eur J Ca Prev 19:366, 2010528 breast (Copen Ht St)Increased mortality Baumann Plas Rec Surg 125:1335, 2010228 br recon, prosp (MDACC)Increased fat necrosis Dragun Cancer 117:2590, 201111914 Tumor registryDecreased OS Cowen Br Ca Res Treat 121:627, 2010141 postop recon, (prospective)Increased implant failure Li J Clin Oncol 27:5312, 20091089 unilateral ER+ breastIncreased contralateral breast CA Stefan J Neurooncol 94:221, 20091274 stroke unit pts (+/- Ca)Increased thrombosis, similar stroke risk as in non-cancer patients Wadhwa Br Ca Res Treat 117:357, 2009152 traztuzumab ptsIncreased cardiomyopathy risk (~5 fold) Dal Maso Int J Cancer 123:2188, 20081453 breastIncreased OM and DSM McCarthy Plas Rec Surg 121:1886, 20081170 breast, surgery (MSK)Increased complications and recon failure Sagiv JNCI 99:365, 20071273 breast with post dx assessIncreased OM and DSM Jagsi Cancer 109:650, 2007828 breast, sx+RTIncreased MI and MI req intervention Sorenson Eur J Surg Oncol 28:815, 2002415 mastectomy (prospective)Increased infection, necrosis, epidermolysis

20. Hematologic Outcomes StudyPopulationOutcome (Smokers) Lieberman Clin Vaccine Immunol 15:49, 2008 72 non-cancer womenDecrease IL1B, IFN-g, IL-6, IL-10, and cytokines in cervical mucus Varadarajan Int J Cancer 2011180 AMLIncreased mortality Ehlers BMT 46:285, 2011148 AML/ALL (Mayo)Increased hospital stay/admit and mortality Marks Biol BMT 15:1277, 20092818 CMLIncreased treatment related mortality, decreased DFS and OS Thomas Cancer 113:3248, 200874 long term ALL survivorsDecreased bone mineral density Chang Cancer 101:782, 2004114 allogenic stem cell txpl1.7% increase in recurrence per PY Chelghoum Ann Oncol 13:1621, 2002643 AMLDec DFS, OS, remission, Inc infection Herr Am J Hematol 34:1, 1990122 CMLIncreased blast crisis, decreased OS Archimbaud Cancer 63:2060, 1989173 CMLYounger, early blast crisis, decreased OS Thalamini Int J Cancer 122:1624, 2008268 NHLDecreased OS Moser Haematol 91:1481, 2006748 NHLIncreased second malignancy Moser Clin Lymphoma Myel 6:122, 2005757 aggressive NHLIncreased carciovascular disease Lorigan Lancet Oncol 6:773, 200519046 HDIncreased synerg risk of lung cancer with RT and/or alkylating agent

21. Smoking Cessation and Outcome StudyPopulationOutcome (Smokers) Chen BJU Int 100:286, 2007265 NMI bladder CACurrent increase recurrence, recent quitters (<1yr) reverse risk Barnoya Ca Causes Cont 15:689, 2004 California SEER analysis from 1975-99 Tobacco control programs reduced lung cancer mortality Aveyard BJU Int 90:228, 2002Bladder Cancer reviewDecreased OS, cessation improve OS Joshu JNCI 103:835, 20111416 prostate, prostatectomy Cessation by 1 year eliminate increased recurrence by current smoking Weinmann Ca Caus Cont 21:117, 2010 768 who died of prostate CA (Pros Ca Screening Mort Study) Most recent smoking status most important predictor for prostate cancer death

22. Smoking, Hodgkins, and Lung Cancer Risk of lung cancer in 19,046 HD patients –In former smokers (prior to diagnosis) HR for lung cancer 4-9 –In current smokers (at diagnosis) HR 6 with smoking HR 20 with smoking + radiotherapy (RT) HR 16 with smoking + alkylating agent (AA) HR 49 with smoking + RT + AA 1. Lorigan Lancet Oncol 6:773, 2005 2. Travis J Natl Cancer Inst 94:182, 2002

23. Prostate, Breast, and 2 nd Malignancy Bladder cancer risk in 9780 prostate cancer patients (CaPSURE) 1 –HR 1.6 with RT alone –HR 2.1 with smoking –HR 4 with smoking + RT Lung cancer risk in 477 breast cancer patients (Conn) 2 –RT alone no increased risk –HR 6 with smoking alone –HR 19 (11 cont., 38 ips.) with smoking + RT 1. Boorjian J Urol 177:883, 2007 2. Kaufman J Clin Oncol 26:392, 2008

24. The Bigger Picture 1. Bittner IJROBP 72:433, 2008 1354 prostate patients treated with brachtherapy +/- androgen deprivation (1995-2004) –475 low risk –636 intermediate risk –243 high risk Cause of Death in Low Risk Pts Cause of Death in High Risk Pts

25. The Bigger Picture 1. Bittner IJROBP 72:433, 2008 Cause of Death % of Total Deaths HR for Current Smokers Cardiopulmonary disease 50.3%3.05 Other15.5%5.52 Gastrointestinal cancer 12.4% 4.09 Lung cancer9.9% Other cancers3.1% Prostate cancer8.7% Treatment (surgery, radiotherapy, androgen deprivation and duration) all focus on optimizing a relatively low percentage of deaths What about the larger percentage?

26. Smoking at Diagnosis and Survival Analysis TypeCurrent vs. FormerCurrent vs. Never Overall Mortality (Cox Prop HR) 1.29 (95% CI 1.17-1.29) 1.38 (95% CI 1.23-1.54) Disease Spec. Mortality (Cox Prop HR) 1.23 (95% CI 1.09-1.39) 1.18 (95% CI 1.03-1.36) 3-year Overall Mortality (Log Reg) 1.50 (95% CI 1.19-1.89) 1.45 (95% CI 1.14-1.85) 3-year Disease Spec. Mortality (Log Reg) 1.57 (95% CI 1.22-2.01) 1.43 (95% CI 1.10-1.84) Adjusted for disease site, gender, age, stage, race, diagnosis date, body mass index, and pack year smoking history Warren Int J Cancer 2012 Apr 26. doi: 10.1002/ijc.27617

27. Smoking at Diagnosis and Survival

28. Warren Int J Cancer 2012 Apr 26. doi: 10.1002/ijc.27617 Smoking at Diagnosis and Survival

29. A Recent NEJM Article Herbst RS et al. (2008) N Engl J Med 359: 1367

30. A Recent NEJM Article Herbst RS et al. (2008) N Engl J Med 359: 1367

31. Effects of Smoke or Nicotine on Cancer Cells in Vivo Nicotine NNK SNP of G-prot, B-Adr-R 42 Oxidative stress CAT SOD 117 A549 xenograft EGF Increased tumor size and weight Angiogenesis 15 Enhanced by estradiol Chick Allantoic Membrane Model (lung, colon, breast) 16 b-FGF 16 VEGF MAPK ERK 1/2 16 Gastric CA xenograft 20, 68 COX-2 VEGFR 20 Cyclin D1 NF  B 46 Gastric CA xenograft COX-2 MEK 68 Syngenic mouse colon cancer CMT93 Angiogenesis Increased tumor size and weight 92 Gastric CA xenograft 96 EGFR c-Src 96 Lewis Lung CA nAChR 98 98, 135 98, 135 98 SHS Chronic nic rat liver CYP 2E1 106 VEGF MCP-1 98 Rat brain 109 NNK Genome Instability 1 117 Warren GW et al. (2008) IJROBP 72: S715

32. Effects of Nicotine on Cancer Cells Nicotine Bax P PP2A Bcl-2 Bax 4 4 HL-60: 22 HT-3: 176 H esoph SCCA: 9 H gastric adeno: 20, 68 MES: 86 ME-180: 58, 176 PC12: 140 SH-SY5Y: 147 SW1116: 74, 96 U2OS: 57 UMSCC: 160 Apoptosis 4, 61 Cer 4 Mito β Adr R: beta adrenergic receptor Cer: ceramide Mes: mesothelioma cells Mito: miochondria Cyt c 4 4 Camptothecin, Cisplatin, Gemcitabine, Taxol, Etoposide, Menadione Paclitaxel, UV light, γ irradiation 6 6 6 Apoptosis or cell death (inhibited) p53 XIAP Survivin  3 nAChR Akt 6, 51 6 E2F1 6, 51, 60, 61, 78, 127, 160 6 6 6 6, 61 6, 51, 60 6 NF  B 7, 51, 86 FHIT Gene Methylation 9 9  7 nAChR 4 4 c-SrcPKC-iota Migration Invasion 18 18, 60 18, 96 18 Cer 18 Proliferation 15, 51 VEGFRCOX-2 20, 68 20 VEGF 20 20, 68 Migration Invasion 20 MMP2 MMP9 20 Angiogenesis Chromatin decondensation, histone acetyl or phos nAChR cJun 22 51, 140 NNK 51 P NNK 20 51, 72 Cyclin D1 51 ERK 1/2 P 57 58, 96 TGF β 58 58, 96 EGFR 58, 96 60 BadBcl-XL Bad P 60 18 NNK 60 β Adr R 60 PP2 60 NNK 60 PKC NNK β Adr R 60 c-Src 60 PI3K 61 Nicotine 60 61 ERF CalpainMAPK Calpain 66 68, 127 66 ERK 1/2 P 68 Proliferation 68 Bcl-2 P 72, 186 72, 127 ERK1/2 MEK 72, 127 c-myc P  7 nAChR 72 PLC 72 72, 127 G1/S progression 72 COX-2  7 nAChR 5-LOX 74, 86 74, 86 74 NF  B 74 96 74 PI3K β Adr R 78 PKCRaf MEK 78 78, 127 78 MAPK 86 96 c-Src 96 MMP2 MMP9 96  7 nAChR 51 GSK3mTORFKHR S6K1 51 Akt P 127 PKC 127 Nicotine Hypoxia, cisplatin DNA frag, PM degradation G1 arrest 140 140, 160 PKA 147 A549: 4, 6, 7, 15, 60, 61, 78 CaSKI: 58 HeLa: 58 H1299: 72 H157: 51 H1703: 51 H322: 199 H460: 18 H69: 51, 72, 127 H82: 72, 127 cJunGADD153 160 EGF 176 Ca influx 186 cJun 195 Raf-1 β Adr R 199 Akt P Warren GW et al. (2008) IJROBP 72: S715

33. Effects of Nicotine on Normal Cells Nicotine NNN Inc ER exp + proliferation 79 Transformation 101, 206 Arecoline HBF cytotoxicity + 161 BEP2D: bronchial epithelial cells CHO: chinese hamster ovary cells GK: gingival keratinocytes HBEC: human bronchial epithelial cell HBF: human bronchial fibroblast Het-1A: human esophageal cell HOK: human oral keratinocytes HPDE6-c7: human pancreatic cell HUVEC: human vascular endothelial cell MEC: mouse epithelial cell MIC: murine immune cells PNEC: pulmonary neuroendocrine cell RLE: rat lung epithelium VSMC: rat aortic vascular smooth muscle cells GRPR 188, 230, 240 NNK  3 nAChR  7 nAChR  3 nAChR  7 nAChR 8, 122 8 Anchorage indep growth, proliferation, micromets, inhibited apoptosis NF  B STAT-1 Bcl-2 MAPKERK 1/2 JNK 3 40 HPLID: 199 HUVEC: 20, 135 HPDE6-c7: 32 RLE: 40 MEC: 64 MIC: 159 PNEC: 183 VSMC: 200 Migration VEGFR COX2 20 Gastric CA Co-culture β Adr R AC EGFR P ERK 1/2 P MEK Proliferation 32, 199 32 Ras 40 PKC PI3K 40  3 nAChR 46 ERK 1/2 Cyclin D1 46 Rb P 46 nAChR 64 Raf 64, 211, 212 Cyclin D1 64 Serum Starvation G1 Growth Arrest (inhibited) 64 8 8 PI3K Akt P 122 GSK3 S6K 4EBP-1 FKHR 122 Apoptosis (inhibited) UV light, H2O2, Etoposide 122 nAChRα7 nAChR 135 Angiogenesis 135 MEK PI3K NF  B 135 Apoptosis (inhibited) UV light, Dexamethasone, staurosporine cyt c caspase 156, 159 252 BEP2D: 213 CHO: 201 GK: 211 HBEC: 3, 46, 101, 122, 255 HBF: 230, 240 Het-1A: 8, 206 HOK: 212  7 nAChR 183 183, 211, 212 183 Raf-1 199 nAChR MEKERK 1/2 EGFR VEGFR 200 201 DNA synthesis COX LOX 201 STAT-3 211 Sidestream smoke 211, 212 NF  B 212 NNN NNK Nicotine nAChR  7 nAChR 213 iNOS 252 NF  B 213, 255 Warren GW et al. (2008) IJROBP 72: S715

34. Nicotine in Xenografts Warren GW et al. Int J Cancer 2012

35. Nicotine in Xenografts Warren GW et al. Int J Cancer 2012

36. Nicotine and HIF-1α Nicotine a7nAChR PI3Kp-Akt Ras Raf MEK ERK 1/2 Proliferation, Invasion, VEGFR, EGFR Production Inhibition of Apoptosis HIF-1α Warren GW et al. (2008) IJROBP 72: S715 Zhang Q et al. (2007) Clin Cancer Res 13: 4686 mTor PKC SFK VEGF HYPOXIA

37. Warren Int J Cancer Mar 24 doi: 10.1002/ijc.27556, 2012 Nicotine and HIF-1α in Xenografts

38. Tobacco, Nicotine, and Tumor Failure Warren Int J Cancer Mar 24 doi: 10.1002/ijc.27556, 2012 and unpublished data

39. Oncologists and Cessation Survey in 601 urologists 1 –55.6% never discuss cessation –40.7% believe cessation does not affect outcomes –37.7% do not feel qualified to counsel –93.7% have never had cessation training 1. Bjurlin J Urol 184:1901, 2010

40. Tobacco Assessment Practices Thoracic oncology providers from IASLC asked about tobacco use assessment, cessation, and perceptions of tobacco 1,507 respondents –28.6% from Europe, 22.8% from US, 12% from Japan –86.7% with MD degree 33.4% medical oncology 24.3% surgery 18.7% pulmonary medicine 8.8% radiation oncology

41. Tobacco Assessment Perceptions ParameterAgree/Strongly Agree Tobacco affects outcomes91.7% Cessation should be standard 90.2% “I have adequate training”32.7% Clinicians need training82.3%

42. Tobacco Assessment Practices ParameterEvaluation at Initial Visit (always/most) Evaluation at Follow-up (always/most) Ask if use tobacco90.2%73.5% Ask if will quit78.9%71.6% (ask if they quit) Advise to quit80.6%70.8% (reinforce quit) Discuss medications40.2% Actively treat38.8%

43. Tobacco Assessment Barriers ParameterAgree/Strongly Agree Can’t get patients to quit58.4% No effect on cancer outcome11.9% Lack of time44.9% Limited reimbursement31.2% Patient resistance67.3% Lack of training47.7% Lack of available resources47.5%

44. 155 Cooperative group clinical trials analyzed for tobacco use –10 cooperative groups –Any tobacco use –Detailed former tobacco use –Detailed current tobacco use –Assessments at follow up –Cessation assessment/advice/counseling Warren Proc AACR abs. 648, 2012 Peters EA et al. In Press, J Clin Oncol, 2012 Assessing Tobacco in Cooperative Groups

45. Any Assessment of Tobacco (29%) No Assessment of Tobacco (71%) Warren Proc AACR abs. 648, 2012 Peters EA et al. In Press, J Clin Oncol, 2012 Assessing Tobacco in Cooperative Groups

46. Self Reported Tobacco Use 1. Warren GW et al. Radiother Oncol 103:45,2012 2. Khuri Cancer Epid Biomarkers Prev 10:823, 2001 Self-reported tobacco use correlated with serum cotinine in 50 head/neck cancer patients during RT/CRT –29.4% of tobacco users required biochemical confirmation to accurately identify tobacco use Cotinine confirmed tobacco use in 39% of recent quitters in 1191 patient retinoid prevention trial 2

47. False Reporting Rates LungBreastProstateOverall Current0% (n=10) 0% (n=10) 0% (n=10) 0% (n=30) Recent Quit 55.6% (n=27) 27% (n=27) 0% (n=11) 35.4% (n=65) Former0% (n=30) 0% (n=30) 6.3% (n=48) 2.8% (n=108) Never0% (n=10) 0% (n=10) 0% (n=10) 0% (n=30) Warren GW et al. Proc SRNT 2012

48. Predictors of Misrepresentation CategoryUnivariateMultivariate Genderns Race (white vs. non-white)ns Disease site (lung vs. breast vs. prostate)0.0040.052 Age at time of questionnaire (under 50 vs. 50+)nsNs Age at starting cigarette habit (under 18 vs. 18+)nsNs Pack year history (<10 vs. 10+)0.0110.059 Ever history of other tobacco use (yes vs. no)nsNs Ever use of nicotine replacement (yes vs. no)nsNs Home secondhand smoke exposure (yes vs no)nsNs Time between blood collection and return of questionnaire (14 days or less vs. >14 days) nsNs Current employment0.0190.055 Warren GW et al. Proc SRNT 2012

49. RPCI Tobacco Assessment Flow All New Patients New Patient Screen Initial Screen Automatic ReferralNo Initial Screen Referral Referral Contact Refuse Intervention Accept Intervention Standard of Care Treatment and Follow-up Established Patient Screen Automatic Referral Individualized Cessation Plan Warren Gw et al., Proc SRNT 2012

50. RPCI TACS Primary screen based upon 3 questions: 1.Have you smoked at least 100 cigarettes in your entire life? (yes, no, refused screen) 2.Do you now smoke cigarettes everyday, some days, or not at all? (everyday, some, not at all) 3.Do you currently use any other tobacco products such as cigars, pipes, chewing tobacco, snuff, dip, SNUS, clove cigarettes, kreteks, or bidis? (yes, no) Categorized based upon response as Current smoker/tobacco use Former smoker/tobacco use Never smoker/tobacco use Warren Gw et al., Proc SRNT 2012

51. TACS First Call Outcomes (10-12-12, 1951 patients referred)

52. RPCI TACS Referral Efficiency (654 Referred Patients) Warren Gw et al., Proc SRNT 2012 Appropriate Referrals contacted by Cessation Service (529 pts or 80.9%) Patients not contacted after 5 attempts (103 pts or 15.7%) Inappropriate Referrals (22 pts or 3.4%)

53. First Call Stratification (529 Patients Contacted for Cessation) Warren Gw et al., Proc SRNT 2012 Quit Commitment (298 pts or 56.3%) Unable to Participate (32 pts or 6.0%) Refuse any intervention (14 pts or 2.6%) Precontemplation (49 pts or 9.3%) Contemplation (131 pts or 24.8%)

54. TACS Most Recent Outcomes (10-12-12) 31.7% quit rate, 2.8% “don’t contact me” rate

55. New Patient Screen Yield Referral Question% of Total Referrals for Current Users % of Total Referrals for Former Users % of Total Referrals Do you now smoke cigarettes everyday, some days, or not at all? 93.7%83.1% Do you currently use any other tobacco products such as cigars, pipes, chewing tobacco, snuff, dip, SNUS, clove cigarettes, kreteks, or bidis? 6.3%5.6% About how long has it been since you last smoked a cigarette, even a puff? 89.0%10.1% About how long has it been since you last smoked/used other tobacco products such as cigars, cigarillos, little cigars, pipe tobacco, or used chewing tobacco, snuff, dip, or SNUS even once? 1.4%0.2% Are you currently using any of the following methods or strategies to try to quit? 2.7%0.3% Are you interested in stopping tobacco use or speaking with our tobacco cessation specialist? 6.8%0.8% 98.8% of patients captured with 3 questions

56. Established Patient Screen Yield Referral Question% of Total Referrals Since your last visit to (the Institute) or within the past 30 days, have you smoked a cigarette, even 1 or 2 puffs 89.7% Since your last visit to (the Institute), have you used any other tobacco products such as cigars, pipes, chewing tobacco, snuff, dip, SNUS, clove cigarettes, kreteks, or bidis? 3.4% Are you currently using any of the following methods or strategies to try to quit? 5.1% Would you like to speak with our tobacco cessation specialist? 1.7% 98.3% of patients captured with 3 questions

57. Referral Rate Comparison for 100 smokers identified with screening Referral MethodVoluntary (traditional) Mandatory Patients Screened100 Cessation Referral Rate 20%100% Patients Referred for Cessation 20100 Quit Rate35%23% Patients Who Quit723

58. Tobacco and Cancer: Cost Considerations RPCI TACS cost projections –8000 patients screened annually –2000 patients referred annually –3.5 FTE to manage patients (quitline trained) –23% 7 day point prevalence quit –35% quit/1cig or less per day –$225,000 annually (~$113 per referred patient) –Equivalent to ~ 75 ICU days at $3000 per ICU day (i.e. break even if I save 75 ICU days in 2000 referred patients per year)

59. Incentives for Tobacco Cessation Improved cancer treatment outcomes; Improved non-cancer related health benefits; Improved quality of life; Decreased treatment related toxicity; and Decreased healthcare costs

60. What Must Be Done Standardized tobacco assessments Mandatory assessment of tobacco at diagnosis, during treatment, and during follow-up Mandatory referral to dedicated (educated) tobacco cessation resources Increasing research emphasis to improve cessation efficacy in cancer patients Improving access to care through improved reimbursement and coordination between clinicians, cancer centers, insurers, and community resources.

61. The Support that Makes This Possible The Lab Michelle Romano Janelle Mackowiak Samantha Sobus Nicci Moran Krista Pundt Katie Dobson Dr. Essie Torres The Clinic Dr. Mike Kuettel Leayn Flaherty Dr. Jorge Gomez Dr. David Mattson Dr. Kilian May Dr. Dheerendra Prasad Dr. Anurag Singh

62. RPCI Contributors Administrative Dr. Candace Johnson Maureen Kelly Mary Ann Long Rob Reed Pat Hysert Pam Germain Dana Jenkins Information Technology Jen Epstein Kevin Kimball Statistics Dr. Alan Hutson Clinical Research Support Cynthia Nowadly Dr. Joyce Yasko The Man at the Top Dr. Donald (Skip) Trump Tobacco and Epidemiology Dr. James Marshall Dr. Mike Cummings (now at MUSC) Dr. Andy Hyland Dr. Richard O’Connor Dr. Mike Zevon Dr. Mary Reid Pat Hysert Dr. Martin Mahoney The New York State Quitline Clinical Dr. Michael Kuettel Dr. Anurag Singh Dr. Todd Demmy Dr. Elizabeth Dexter Dr. Chumy Nwogu Dr. Sai Yendamuri Dr. Jorge Gomez Dr. Grace Dy Dr. Hongbin Chen Dr. Alex Adjei Dr. Thom Loree (now at ECMC)

63. Additional Collaborations University of Kentucky Dr. Mahesh Kudrimoti Dr. Marc Randall Dr. Ronald McGarry Dr. Vivek Rangnekar Dr. Susanne Arnold Dr. Joseph Valentino Dr. Brent Shelton Dr. Thomas Gal Dr. Leslie Crofford Jackie Sims (retired) Laura Reichel Dr. Michael Cibull Dr. Richard Kryscio Ken Westberry Dr. Mark Evers Other Groups AACR ASCO IASLC Alliance (CALGB) Roswell Park Dr. Irwin Gelman Dr. Youcef Rustum Dr. Karoly Toth Mary Vaughan Dr. Thomas Schwaab Dr. Scott Abbrams Dr. Mukund Seshadri Dr. Christine Ambrosone Mary Nesline Dr. Stephen Edge Nancy Watroba Other Institutions Dr. Ellen Gritz (MDACC) Dr. Benjamin Toll (Yale) Dr. Roy Herbst (Yale) Dr. Anthony Alberg (MUSC) Dr. Matthew Carpenter (MUSC) Dr. Srikumar Chellappan (Moffitt) Dr. Carolyn Dresler (Arkansas DOH) Dr. Erica Peters (Yale)