Zosia Chustecka

October 17, 2017

YOKOHAMA, Japan ― Smoking is the overwhelming cause of most lung cancers, so control over tobacco should be of ultimate importance to everyone involved in dealing with this disease.

"This is our fight ― we cannot deal with lung cancer and not fight against tobacco," urged Mary Reid, PhD, professor of oncology and director of cancer screening and survivorship at the Roswell Park Cancer Institute, Buffalo, New York, speaking here at a packed plenary session of the 18th World Conference on Lung Cancer (WCLC).

"We have an obligation to fight the use of tobacco products at every turn in every country," she said.

Worldwide, lung cancer is the most common cancer, excluding local skin cancers, and it remains the greatest cause of cancer deaths globally, she reminded the audience.

This translates to 1.82 million new cases of lung cancer and 1.59 million deaths a year ― 19% of all cancer deaths worldwide.

There are more than 1 billion smokers worldwide, and because of ageing populations and the global entrenchment of tobacco use, the prevalence of lung cancer will remain unacceptably high for at least several decades, she warned.

But the tide is changing. Countries that have enacted tobacco control policies are seeing a decrease in both smoking rates and the incidence of lung cancer.

A case in point is the United States, where 80% of lung cancer cases are attributable to smoking. Dr Reid showed a slide (below) demonstrating how the decrease in smoking is mirrored by a decrease in male deaths from lung cancer.


In the United States, the effort to control tobacco was led by California, starting in the late 1980s. The drop in lung cancer deaths was seen after 3 to 5 years, noted Carolyn Dresler, MD, from the US Human Rights and Tobacco Control Network, speaking at the same plenary session. (Dr Dresler is also with the Center for Tobacco Products, US Food and Drug Administration [FDA], but was not attending the meeting in that capacity and emphasized that the opinions expressed are her own and cannot be attributed to the agency).

"With better tobacco control, with resultant smoking cessation, many other countries have similarly seen a decline in the deaths from lung cancer, mostly in Western, high-income countries," she said.

Although this is good news, the problem has not gone away. Dr Dresler reminded the audience that overall, tobacco use is thought to be responsible for 7 million deaths per year worldwide (from all causes, including the 1.6 million deaths due to lung cancer mentioned above).

Despite policies to control tobacco, the tobacco industry is not backing off. It has produced new products to replace conventional cigarettes ― electronic cigarettes (e-cigarettes), electronic nicotine delivery systems (ENDS), and novel "heat not burn" (HNB) devices.

Claimed to Be Less Harmful

In an interview with Medscape Medical News, Dr Dresler explained that HNB products contain tobacco, but the delivery device heats the tobacco rather than burns it, and some HNB devices contain a liquid that "has been passed over tobacco," she said. e-Cigarettes are different in that they contain nicotine, but no tobacco, she added.

Both types of products are claimed to be less harmful than cigarettes, and studies have shown that they contain less toxicants and fewer carcinogens. Most of those studies have been carried out by the tobacco industry, but a few independent studies of e-cigarettes have found fewer toxicants, she said.

However, with any of these products, there are as yet no epidemiologic data regarding lung cancer or other diseases, she pointed out.

Regulatory reactions to e-cigarettes have varied around the world, Dr Dresler noted in her talk. They have been banned in Singapore, Australia, and Canada (although Australia and Canada are now reconsidering this ban). The United Kingdom is "overwhelmingly supportive" of their use, she said. (A Public Health England document concluded that they are 95% safer than cigarettes and are useful for cessation, as reported by Medscape Medical News.) In the United States, the FDA has put off regulating e-cigarettes until 2020. In Japan, e-cigarettes are available but are not permitted to contain nicotine.

The latest new thing is HNB, and one of these products is already making a huge splash commercially.

It is being marketed as iQOS (an acronym for "I quit ordinary smoking") by Philip Morris International (PMI), one of the largest transnational tobacco companies in the world. PMI markets Malboro cigarettes, one of the leading brands in the world. It is now marketing iQOS products (including a brand named Malboro HeatSticks) as a replacement.

The Marlboro HeatStick

iQOS products were first launched in Japan in 2014, where they were so popular that lines formed outside of shops to buy them. Marketing is now underway in other countries. The company has applied to the FDA for a "reduced harm" claim for the product, but they are not marketing iQOS products in the United States and they cannot until they are authorized to do so, Dr Dresler said.

"Why does all of this matter to us?" she asked the audience of lung cancer specialists.

"Because, where Marlboro goes, so goes the market," she answered. She predicted that "we will see a tsunami of these [HNB] products in the next few years."

We will see a tsunami of these [HNB] products in the next few years. Dr Carolyn Dresler

"This is the biggest revelation of WCLC 2017 ― this impending tsunami of 'heat not burn' products from industry," tweeted Mathhew Evison, MD, consultant in respiratory medicine (thoracic medicine) at the Hospital of South Manchester, United Kingdom.

In her talk, Dr Dresler quoted PMI Chief Executive Officer Andre Calantzopoulos, who commented on the fast uptake of HNB products in Japan (reported by the Nikkei Asian Review), saying, "If you extrapolate the figures, then logically we could reach the tipping point in five years. That is when we could start talking to governments about phasing out combustible cigarettes entirely."

This is the industry's vision of the future ― cigarettes will eventually disappear, but novel products containing tobacco or nicotine will continue to be marketed, with an emphasis on the idea that use of such products is not the same as smoking.

Indeed, PMI has recently invested $80 million in the Foundation for a Smoke-free World, a highly controversial entity that has been met with skepticism among tobacco control experts and that has been condemned by the American Cancer Society and the World Health Organisation, as well as the Lancet, as reported by Medscape Medical News.

Anybody who believes that they really do want to see a smoke-free world is, we argue, living in a fantasy world. Dr Martin McKee and colleagues

"PMI, like other tobacco companies, may well want to sell a range of products, but anybody who believes that they really do want to see a smoke-free world is, we argue, living in a fantasy world," a group of researchers, with senior author Martin McKee, CBE, MD, DSc, from the London School of Hygiene and Tropical Medicine, United Kingdom, wrote in a Lancet commentary. "The public should be aware that Big Tobacco remains as it was, the main cause of premature death and disability from the world's most preventable pandemic," they added.

Big Changes Ahead

iQOS and similar products offer something new to smokers who want to quit. Manufacturers claim that the products will provide users with nicotine and so will continue to support their addiction, while at the same time removing the "harm" from smoking, Dr Dresler told the WCLC audience.

"Of course, it is not known if this is true until changes are seen in the incidence of tobacco-induced diseases, including of lung cancer," she commented.

Of course, it is not known if this is true. Dr Carolyn Dresler

"But if there is a dramatic change from what people have smoked in the past and what they change to smoke in the future, there may be dramatic differences in lung cancer incidences and probably of the type of lung cancer," she said. Hence, the prominence that was given to her talk at the first plenary session at the WCLC, which is organized by the International Association of the Study of Lung Cancer (IASLC).

"For us in IALSC, we can hope that electronic cigarettes and heat-not-burn products do cause less lung cancer as people who smoke cigarettes quit, even if they transition to heat-not-burn cigarettes or electronic cigarettes," she said..

However, she added that it as yet unknown "whether people who use either heat-not-burn or electronic cigarettes ― who quit smoking cigarettes ― will have fewer lung cancers in the very near future."

In an interview with Dr Dresler, Medscape Medical News asked whether this change in which people swap from cigarette smoking to using these newer, apparently less harmful products could be a good thing.

"Well, it would have to be a complete switch," Dr Dresler answered, "with no more cigarette smoking at all, as otherwise, you would not reap the supposed benefits.

"Even smoking a single cigarette per day maintains your cardiovascular adverse risks," she pointed out.

"If you switch completely, then the risks should go down, but what people do is they use a mix of these products, so they use an HNB or an e-cigarette but also carry on smoking, maybe just not as much as before." For example, in Italy, people tend to use both, and that seems to be the pattern in other countries as well, whereas in Japan, people do seem to be switching to the new HNB products.

If people do manage to switch completely to the newer products, and there is a reduction in harm, there should be fewer people dying from tobacco-related diseases, Dr Dresler commented.

Such a prediction was recently made in a study published in Tobacco Control, which used modeling to show that millions of lives could be saved by switching from smoking to the use of e-cigarettes, as reported by Medscape Medical News. In the most optimistic scenario, the authors estimated that switching from conventional cigarettes to e-cigarettes over a 10-year period would yield 6.6 million fewer premature deaths, with 86.7 million fewer life-years lost. In the pessimistic scenario, 1.6 million premature deaths would be averted, 20.8 million fewer life-years would be lost.

However, tobacco control experts cautioned that further study is needed, because there are many unknowns. In particular, e-cigarettes are unregulated, there are more than 300 varieties, and they have not been available for long. Margie Clapper, PhD, deputy scientific director and coleader of the Cancer Prevention and Control Program at Fox Chase Cancer Center in Philadelphia, Pennsylvania, said: "The conclusions made in this article are unsubstantiated by concrete data.

"We do not know what the health risks of e-cigarette use are and may not know for decades," Dr Clapper told Medscape Medical News.

Dr Reid, Dr Dresler, Dr McKee, and Dr Clapper have disclosed no relevant financial relationships.

18th World Conference on Lung Cancer (WCLC). Abstracts PL 01.01 (Dr Dresler) and PL 01.03 (Dr Reid), presented October 16, 2017.

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