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As 44th Smokeout approaches, higher smoking rates persist among at-risk groups

Including people with mental illness, substance abuse issues, limited education, lower-ranking military members, and more

Smoking rates have dropped so dramatically in the U.S. that many people can go days, weeks, or even months without being exposed to tobacco smoke. But while smoking has begun to disappear from the mainstream, some specific subpopulations continue to have high prevalence of cigarette smoking.

For the 44th American Cancer Society Great American Smokeout on Thursday, November 21, we are highlighting the hidden epidemic of smoking in some populations, including individuals in lower education and/or socioeconomic groups, in certain racial/ethnic groups, living with substance abuse and/or mental illness, and in the military.

Adult smoking rates dropped from 42% in 1965 to 14% in 2017. But as highlighted in a recent report by American Cancer Society investigators, tobacco use and its disease impact are increasingly concentrated among at-risk and frequently overlapping populations:

Education: Fifty years ago, the difference in smoking rates between the most and least-educated was small: nearly 40% of college‐educated individuals smoked compared to 45% of individuals in all other education groups. Five decades later, 6.5% of college‐educated individuals smoke, while the rate is more than three times higher among those with a high school education or less (23.1%).

Poverty: Although all income groups experienced declines in smoking over the last few decades, the largest relative decreases have been with higher socioeconomic groups. In 2015 and 2016, tobacco use was about 10% for adults in higher income households (greater than 400% of the Federal Poverty Level) compared to almost 25% of adults in households below the poverty line .

Race/Ethnicity: Among all racial and ethnic groups, there has mostly been a downward trend for both men and women, but there also remains considerable variation. Individuals who are of American Indian or Alaskan Native descent exhibit the highest smoking prevalence (24.3% men and 23.4% women), and women in this group also experienced a recent upward trend (after a nearly two‐decade decline). Individuals of Asian and Hispanic/Latino descent demonstrate the lowest prevalence (12.6% men and 3.5% women). The reasons for  these differences are not well understood, although some research suggests that social and cultural differences and/or practices may explain some of the variation.

Mental Illness: The burden from smoking is particularly high in individuals living with mental illness. Evidence suggests that some individuals with mental illness may have a genetic predisposition toward addiction and/or may self‐medicate using nicotine. Past 30‐day cigarette smoking use among people with a past‐year serious mental illness was more than double those without a past‐year mental illness (27.9% versus 12.9%).

Substance abuse: The burden from smoking is similarly high on individuals with substance use disorders. About three-quarters of people (74%) ages 12 and older receiving substance abuse treatment reported smoking in the past year.

Sexual Orientation: Smoking prevalence rates among lesbian, gay, bisexual, and transgender (LGBT) men and women in the United States are much higher than those among heterosexuals (20.3% vs 13.7%). The social stresses of living in a society that can be hostile to individuals in the LGBT community contribute to the higher prevalence. In addition, the tobacco industry has marketed specifically to the LGBT community for many years, placing advertisements in community media outlets, attending pride festivals to hand out coupons for discounted cigarettes, and promoting their products in LGBT bars to gain customers and leverage aligned groups in the industry's fight against smoking bans.

Military: As in the U.S. population overall, smoking in the military has trended significantly downward in recent decades. In 1980, more than half of military personnel reported smoking. By 2011, smoking rates had dropped to less than one‐quarter. For enlisted service members in the lowest four pay grades, 30% were smoking in 2011. In contrast, tobacco use in the highest six pay grades of commissioned officers had dropped below 5%.

“Eliminating disparities in tobacco use through approaches specifically geared toward these populations is vital to continue to drive smoking rates down and to reduce health disparities”,” said Rich Wender, MD, our chief cancer control officer. “Increased attention to and support for novel interventions, such as  targeted cessation and tobacco control efforts to counter the tobacco industry's marketing efforts, are crucial going forward to reduce tobacco’s continued high impact on death and disease.”

Smoking accounts for nearly 1 in 3 cancer deaths in the U.S., and increases the risk cancers of the lung, mouth, larynx (voice box), pharynx (throat), esophagus (swallowing tube), kidney, cervix, liver, bladder, pancreas, stomach, and colon/rectum, as well as for myeloid leukemia.

Smoking not only causes cancer, it damages nearly every organ in the body, including the lungs, heart, blood vessels, reproductive organs, skin, eyes, and bones. About 1 out of 5 (480,000) deaths in the U.S. is due to smoking.

Since 1976, the American Cancer Society has hosted the Great American Smokeout, a public awareness event to encourage people to quit smoking. It is held on the third Thursday of November.

For more information, visit cancer.org/Smokeout.


  • Please complete our follow-up health equity survey by Nov. 22

    Your input will be used to create new tools to help reduce cancer disparities

    Last year, we asked you to share what you know about health equity through a survey. We are now conducting a follow-up survey to find out your health equity knowledge and what tools we can develop to support continued integration of health equity into your work. 

    We are asking volunteers to take the 10-minute survey by Friday, November 22. 

    Cancer affects everyone, but it doesn’t affect everyone equally. If we are to further reduce deaths from cancer, we must work to achieve health equity by ensuring everyone has the fair and just opportunity prevent, find, treat, and survive cancer. 

    Thank you for your time!


  • Introducing Allied Against Cancer

    New alliance formed to improve access to care in sub-Saharan Africa

    The American Cancer Society’s Global Cancer Control team has long partnered with IBM, the Clinton Health Access Initiative (CHAI), and the National Comprehensive Cancer Network (NCCN) to improve access to cancer treatment for patients in sub-Saharan Africa. This month, the groups announced a new alliance to formalize the organizations’ combined efforts: Allied Against Cancer. 

    The new alliance is dedicated to improving access to high-quality cancer care and treatment in sub-Saharan Africa. It will support a network of African oncology experts and technical assistance partners to improve the quality of cancer care, including collaborating closely with the African Cancer Coalition to establish priorities and execute these initiatives locally.

    Allied Against Cancer will build on much of the work already in progress. These efforts include:

    • Increasing availability and lowering prices for common chemotherapy drugs. ACS and CHAI teamed up in 2016 to bring lower prices for 16 common chemotherapy drugs to six countries in sub-Saharan Africa.
    • Harmonized treatment guidelines. ACS, NCCN, and the African Cancer Coalition recently announced the creation of the NCCN Harmonized Guidelines™ for Sub-Saharan Africa specifically to be used by oncologists across Sub-Saharan Africa. These guidelines have been endorsed by leading cancer centers or health ministries in six countries to date and include treatment guidelines for 46 cancers. 
    • ChemoSafe. This tool promotes safe handling of chemotherapy drugs in cancer centers and supports quality improvement efforts. 

    "Allied Against Cancer brings together a group of top-notch experts to tackle the growing burden of cancer in Africa, and the American Cancer Society is proud to be a founding member of the alliance," said our CEO Gary Reedy.

    There are more than 800,000 new cancer cases each year in Sub-Saharan Africa and incidence is projected to double by 2040. And as these countries address the growing cancer epidemic, data and emerging technologies can play a significant role in cancer treatment control and care. The need for more affordable cancer treatment and strong systems for their delivery are crucial to help improve patients' survival.

    Read more about Allied Against Cancer at alliedagainstcancer.org.

  • ACS awards $1M in CHANGE grants to fight lung cancer

    ​Eight $125,000 grants funded by the NFL will provide lung cancer screenings and smoking cessation help

    Thanks to our partnership with the National Football League and its Crucial Catch program, eight community health centers in NFL markets have been approved for CHANGE grant funding for lung cancer screening and smoking cessation support. 

    Each of the following centers has received a two-year $100,000 grant that runs through Oct. 31, 2021. And, each will have a lung cancer screening partner that will receive $25,000.

    • Blue Ridge Health in Hendersonville, NC  [Carolina Panthers market] – Southeast Region

    • Cambridge Health Alliance in Cambridge, MA [New England Patriots market] – Northeast Region

    • Community Medical Centers Inc. in Stockton, CA [San Francisco 49ers market] – West Region

    • Daughters of Charity Community Health Centers in New Orleans, LA [New Orleans Saints market] – South Region

    • Grady Health Foundation in Atlanta, GA [Atlanta Falcons market] – Southeast Region

    • Northeast Ohio Neighborhood Health Services in Cleveland, OH [Cleveland Browns market]  - North Central Region

    • Progressive CHC in Milwaukee, WI [Green Bay Packers market] – North Region

    • Saint Joseph Hospital Foundation in Denver, CO [Denver Broncos market] – North Region

    The grants are the latest in our Community Health Advocates implementing Nationwide Grants for Empowerment and Equity (CHANGE) program, which provides funding opportunities as part of the ACS’s commitment to reduce cancer disparities.

    Lung cancer is the leading cause of cancer death among both men and women in the U.S., responsible for about 1 in 4 cancer deaths. Lung cancer is the second most common cancer diagnosed in both men and women but takes more lives than any other cancer. Each year, more people die of lung cancer than of colon, breast, and prostate cancers combined. We estimate there will be about 228,150 new lung cancer cases and 142,670 lung cancer deaths in the U.S. in 2019.

    Lung cancer can be diagnosed in anyone, including those with no known risk factors. Cigarette smoking increases the risk of several cancers and is clearly the strongest risk factor for lung cancer, accounting for about 8 out of 10 lung cancer deaths in the U.S. For smokers, quitting is the best way to reduce the risk of lung cancer and helps lower the risk of developing several other types of cancer. 

    Since 2009, the NFL’s Crucial Catch initiative has raised more than $20 million in support of ACS. Visit nfl.com/crucialcatch to learn more.


  • ACS CAN to Administration: keep your promise to end all flavored e-cigarettes

    New ad urges President Trump to put kids' health over Big Tobacco company profits

    The American Cancer Society Cancer Action Network (ACS CAN) together with the American Academy of Pediatrics, American Heart Association, American Lung Association, Campaign for Tobacco-Free Kids, and Truth Initiative launched an ad campaign this week urging President Trump to protect kids’ lives over tobacco industry profits and follow through on a commitment to pull all flavored e-cigarettes from the market.

    In September, the President, First Lady, and Administration officials committed from the Oval Office to issue comprehensive guidance to clear the market of all flavored e-cigarettes, including mint and menthol, and enforce the guidance on all e-cigarette retailers. Newly released data shows that the youth e-cigarette epidemic continues to get worse. More than 5 million kids now use e-cigarettes, with flavored products being a primary driver for use.

    A statement from the public health groups follows:

    “The ad campaign is in response to recent comments from the President and White House officials that appear to walk back a commitment that the Food and Drug Administration (FDA) would release and enforce comprehensive guidance to clear the marketplace of all e-cigarette flavors and proactively address the growing youth e-cigarette use crisis.

    “Any attempts to weaken this guidance will further fuel the public health epidemic that has resulted from FDA’s delayed regulation of these addictive products and can only be seen as bending to the agenda of the profit-driven e-cigarette industry. Flavor carveouts or exemptions for certain retailers are simply unacceptable and will continue to allow e-cigarette manufacturers to hook a new generation of users by masking nicotine addiction behind flavored products.

    “The Administration, through strong and comprehensive FDA guidance, must protect our children and halt the sale of all flavored e-cigarettes. Our kids’ health isn’t for sale and the President should not cave to industry interests.”

    Watch the new ad.


  • Extended Stay America launches 'Stay Stories'

    ​The first video features a lung cancer patient who traveled from Michigan to Texas for treatment

    A new Extended Stay America (ESA) video campaign called ‘Stay Stories’ launches this month just in time to recognize Lung Cancer Awareness Month.

    The first video in the Stay Story series focuses on lung cancer patient Candace Bennink from Grand Rapids, Michigan, who discusses her stay at an ESA in Houston, Texas, through the Hotel Keys of Hope program. 

    Candace was diagnosed two years ago with a very rare lung cancer and was given eight months to live. She follows a strict diet and is grateful for the ESA kitchen and other amenities which allowed her to maintain her dietary requirements. While she is still undergoing targeted therapy, we are happy to report she is doing well.

    ACS and Extended Stay America (ESA) developed the Hotel Keys of Hope program to provide free or reduced-price lodging to give patients and their caregivers a home-away-from-home close to their nearest treatment facility. Through this program, patients in need are able to receive amenities that reduce the costs and burdens associated with living away from your home for an extended period of time, including fully equipped kitchens, free in-room Wi-Fi, on-site laundry facilities, and pet-friendly room options.

    The “Stay Stories” series will share firsthand stories from the patients who are on the frontlines of the fight against cancer, and audiences across the nation will have an opportunity to hear stories of resilience as these patients reveal their personal journeys. Over the next year, look for these stories to be featured on a dedicated cancer.org landing page and within the Society’s email marketing and social channels.  

    To date, ESA has donated more than 130,000 hotel nights to cancer patients and their families, and have helped over 17,000 cancer patients and their families.


  • Tobacco-Free Generation celebrates another 100% tobacco free campus

    ​Three-year CVS funding has ended; new funding source needed

    In 2016, the American Cancer Society’s Center for Tobacco Control launched a bold initiative – the Tobacco-Free Generation Campus Initiative (TFGCI) – to accelerate and expand the adoption and implementation of 100% smoke- and tobacco-free policies on college and university campuses across the nation. 

    The initiative was initially supported with a three-year $3.6 million from CVS Health. A total of five cohorts, comprised of 107 colleges and universities, have received grant funding to support their work to protect students, faculty, staff, and visitors to campuses since then. Now, three years later, the ACS is celebrating the adoption of stronger smoke- and tobacco-free policies at more than a third of those colleges and universities.

    “TFGCI’s grantees range from small, private colleges such as St. Xavier University, to large, research institutions such as the University of Pennsylvania, and represent almost 1.8 million college students, almost a quarter million faculty, and countless other staff and visitors,” said Bidisha Sinha, MPH, director of tobacco control initiatives at ACS. “We know at least 38 schools or approximately 35 percent of our grantees have adopted stronger policies.” 

    Each school that is awarded a grant receives up to $20,000 to help them advocate for, adopt, and implement 100% smoke- and tobacco-free campus policies. ACS also provides technical assistance and resources and convenes grant winners at an annual summit where they learn from their peers and experts and develop additional relationships to support their work. To earn the 100% smoke- and tobacco-free designation, smoking cannot be allowed anywhere on campus at any time. The policy must also include all tobacco products, including non-combustible products like smokeless tobacco and e-cigarettes. 

    Recent wins include Oregon State University. This message came to ACS from OSU’s leadership after their policy was adopted: 

    We’d like to share our excellent news of the final confirmation of our new 100% Tobacco Free Oregon State University Policy.  This policy covers all tobacco products including e-cigarettes and smokeless tobacco and covers all Oregon State University locations and controlled spaces.  

    Despite the success over the past three years, there is still more work to do. A recent study in the journal Tobacco Control, whose co-authors included Bidisha and Cliff Douglas, ACS’s vice president for tobacco control, found that only 16.7% of accredited, degree-granting institutions in the U.S. had 100% smoke- or tobacco-free policies in 2017, and that slightly more than 25% of full- and part-time college students, faculty, and staff were covered by 100% smoke- or tobacco-free policies.

    “We will be looking at new funding to expand the program to even more schools with a goal of reaching global colleges and universities, as well as technology and vocational schools in the U.S.,” Bidisha said.

    The most recent cohort of TFGCI grantees includes its first school outside the U.S. - Qatar University in Doha, Qatar. Other new grantees include:

    • George Mason University in Fairfax, VA
    • Thomas Jefferson University in Philadelphia, PA
    • Massachusetts College of Pharmacy and Health Sciences in Boston, MA
    • Rutgers School in New Brunswick, NJ
    • Texas A & M University in College Station, TX
    • University of Alabama in Birmingham, AL
    • University of California, Berkeley in Berkeley, CA
    • University of Maryland in College Park, MD
    • University of Washington in Seattle, WA

    “We are very optimistic that, through our energetic, collaborative efforts, ACS’s Tobacco-Free Generation Campus Initiative will continue to expand the list of campuses that adopt strong smoke- and tobacco-free policies,” said Bidisha. “There are only three states with such comprehensive protections at more than half of their colleges and universities. We look forward to helping this list grow.”

    For more information about TFGCI contact Bidisha at Bidisha.Sinha@cancer.org

    PHOTO: Pictured in the top photo, fourth from the left, is Bidisha, with awardees at the Tobacco-Free Generation Campus Initiative Annual Grantee Summit in Atlanta Oct. 15-17. In the smaller photo are representatives from Oregon State University, which recently passed a tobacco-free policy.


  • ACS reacts to American College of Physicians' recommendation that colon cancer screening begin at 50

    On Nov. 4, the Clinical Guidelines Committee of the American College of Physicians (ACP) issued a guidance statement for physicians on colorectal cancer (CRC) screening for adults with average risk. The main recommendations, published in the Annals of Internal Medicine, were the following:

    • All adults ages 50 to 75 of average risk should be screened

    • Suggested tests and intervals include: fecal immunochemical testing (FIT) or high-sensitivity guaiac-based fecal occult blood testing (gFOBT) every 2 years, colonoscopy every 10 years, or flexible sigmoidoscopy every 10 years plus FIT every 2 years

    • Screening should not be done in average-risk adults older than age 75 or in adults with a life expectancy of less than 10 years

    The authors said the aim was to reconcile the differing recommendations from various organizations.

    Below is a response from Rich Wender, MD, our chief cancer control officer:

    "The ACP guidance statement for CRC screening confirms the high value of screening adults for colorectal cancer. The statement also confirms the value of a variety of screening strategies, and providing patients with a choice of options. Validating the importance of screening for the second leading cause of cancer related death in the United States when men and women are combined, once again affirms what has been an accepted and highly valued preventive practice for years. And additional guidance might encourage some clinicians to make this a higher priority. 

    Because of the methods used by the ACP, this new statement may be a source of confusion for some clinicians and the general public. Because of their heavy reliance on clinical trials, particularly randomized clinical trials, and the decision not to rely on modeling data, the potential recommendations are inevitably confined to those approaches to screening that were actually tested in these trials. No trials evaluated beginning screening prior to age 50. In addition, these trials are all somewhat older and some should be judged as being out of date in that they were conducted before the changing epidemiology of CRC and the shift to earlier onset disease was known. It is highly unlikely that another large randomized trial of CRC screening will occur in the U.S., and even if one were to be designed comparing starting ages, the results would not be known for many years. Thus, the ACP methods permit no clear pathway to ever recommend a change in starting age, as the ACS did last year.

    Research conducted by the ACS conclusively demonstrates that the risk for CRC in individuals under age 50 has increased dramatically, particularly for rectal cancer. Modeling based on these new trends provides consistent and compelling evidence that starting screening at age 45 is more efficient than starting at age 50.

    One way to look at this: The risk of colorectal cancer in people age 45 is now virtually the same as the risk at age 50 when some of the clinical trials were first conducted. And the trend of rising risk in young adults is going to continue, and is occurring in many countries around the world.

    While relying on trials is an important and conservative approach to determine the efficacy of screening, once that efficacy is established, we need to move beyond the trials when we need to update a screening guideline based on new data, such as evidence of changing risk of disease. Using other approaches, like modeling, adds to the precision of guidelines."


  • ​Lung cancer can affect anyone, even nonsmokers, yet the stigma persists

    Lung cancer is by far the leading cause of cancer death among both men and women. Each year, more people die of lung cancer than of colon, breast, and prostate cancers combined.

    About 20% of people who die of lung cancer have never used any form of tobacco. Yet, too many people, including health care providers, believe that lung cancer occurs almost exclusively in current or former smokers. As a result, patients may delay getting their symptoms checked and clinicians may be less likely to consider a diagnosis of lung cancer in a patient with symptoms, particularly if the patient is young.  

    “When patients present with symptoms of lung cancer that have persisted for a few weeks without an obvious alternative explanation, they need to be evaluated for lung cancer regardless of whether they ever smoked,” said Rich Wender, MD, our chief cancer control officer (pictured here). “The reality is lung cancer in non-smokers is all too common. In fact, if it were tracked as a separate cancer, it would rank in the top 10 leading causes of cancer death.”  (For more information on why nonsmokers get lung cancer, read this story on cancer.org.)

    Stigma and blame often accompany a lung cancer diagnosis. Finding out you have cancer is devastating. But lung cancer is unique because some people are quick to assume that it is the patient’s fault.  

    “Patients tell us that when they receive a lung cancer diagnosis, the first thing they hear is, ‘I didn’t realize you smoked,’” said Bob Smith, PhD, senior vice president, Cancer Screening. “They feel blamed for their disease.” 

    Tobacco control efforts, which have saved millions of lives, have unfortunately contributed to the stigma, not just against smoking, but also against people who smoke and who have lung cancer.  

    “One of the things we simply must change is the sense that any lung cancer patient feels like they need to tell the people around them that they are not responsible for their cancer,” said Bob. “Even people who previously smoked aren’t to blame. The tobacco industry created and aggressively marketed an addictive product that increases cancer risk.”  

    There is hope today for lung cancer patients. For decades, there wasn't much doctors could do to treat lung cancer. Today, we have a screening test for patients who have no symptoms but are considered to be at high risk due to smoking. We also have new diagnostic tests — including comprehensive biomarker testing — to determine if a patient with an advanced lung cancer will benefit from new targeted therapies. Other patients can be ideal candidates for new immunotherapy agents.  

    “Never have we had so much hope,” said Rich. 

    Reducing tobacco use remains a priority for ACS as we attack cancer from every angle. There are still between 38-40 million people who smoke, and tobacco remains the top cause of preventable death in the U.S., associated with 13 cancers, including lung cancer.

    “Helping smokers quit remains one of the most important public health opportunities we face in our mission to save lives,” Rich said. 

    Visit cancer.org to learn more about lung cancer.




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