Reducing Tobacco-Related Cancer Incidence and Mortality: Summary of an Institute of Medicine Workshop

It has been observed that tobacco use remains a serious and persistent national problem. This report summarizes a public workshop convened by the Institute of Medicine's National Cancer Policy Forum that examined current issues in tobacco control, tobacco cessation, and implications for cancer patients.

Learning Objectives

• Describe strategies that clinicians can implement to reduce the burden of tobacco-related cancers.

• Identify potential actions that could facilitate access to and advance tobacco cessation treatment.

Abstract

Tobacco use remains a serious and persistent national problem. Recognizing that progress in combating cancer will never be fully achieved without addressing the tobacco problem, the National Cancer Policy Forum of the Institute of Medicine convened a public workshop exploring current issues in tobacco control, tobacco cessation, and implications for cancer patients. Workshop participants discussed potential policy, outreach, and treatment strategies to reduce tobacco-related cancer incidence and mortality, and highlighted a number of potential high-value action items to improve tobacco control policy, research, and advocacy.

Implications for Practice:

Tobacco use is the leading cause of preventable death in the U.S.; approximately 30% of all cancer deaths and 80% of lung cancer deaths are due to tobacco use. Substantial evidence also demonstrates that smoking is associated with poor outcomes in cancer patients. The Institute of Medicine’s National Cancer Policy Forum convened a public workshop to examine current issues in tobacco control and tobacco cessation. This article highlights potential high-value action items to improve tobacco cessation treatment and advance tobacco control policy, research, and advocacy. Clinicians play a vital role in reducing the burden of tobacco-related cancers by providing tobacco cessation treatment to their patients.

Introduction

Tobacco use remains a serious and persistent national problem. As the leading cause of preventable death in the U.S., smoking accounts for more than 440,000 deaths annually, including 30% of all cancer deaths, and results in $193 billion in health-related economic losses each year [1, 2]. Recognizing that progress in combating cancer will never be fully achieved without addressing the tobacco problem, the National Cancer Policy Forum of the Institute of Medicine convened a public workshop titled Reducing Tobacco-Related Cancer Incidence and Mortality in June 2012 [3].

The National Cancer Policy Forum convenes representatives from government, industry, and academia, along with other stakeholders, to consider issues in science, medicine, public health, and policy relevant to the goals of reducing the burden of cancer. This workshop gathered experts to examine the current issues in tobacco control and tobacco cessation at the population level and their impact on cancer patient outcomes, and to discuss potential policy, outreach, and treatment strategies to reduce tobacco-related cancer incidence and mortality. This article summarizes presentations and discussion from the workshop, and it highlights a number of potential high-value action items to improve tobacco control policy, research, and advocacy.

Trends in Tobacco Use in the U.S.

Although the U.S. has made progress in reducing tobacco use by reducing adult smoking prevalence from approximately 40% at the time of the first U.S. Surgeon General’s report on smoking in 1964 to 18.9% today [4, 5], progress in reducing tobacco use has slowed. Compared with the overall population, there is a greater burden of smoking in certain population subgroups, including individuals with lower socioeconomic status and educational attainment, individuals with a history of mental illness and/or substance abuse, and military personnel [6–9]. For youth, after several decades of progress in reducing tobacco use, the decline in smoking seems to be slowing (Fig. 1) and is at a standstill for smokeless tobacco use. Preventing tobacco use in youth is critical; according to the 2012 U.S. Surgeon General’s report, 99% of individuals who smoke start by age 26, and nearly 90% of smokers begin by age 18 [10]. According to Dr. Howard Koh, Assistant Secretary for Health at the U.S. Department of Health and Human Services, “It is time to accelerate and reinvigorate our efforts and reaffirm that tobacco use is the premier public health challenge of our time.”

Figure 1.

Percentage of high school students who reported current cigarette use, 1991 to 2011. For all high school students, cigarette smoking increased from 1991 to 1997 and decreased from 1997 to 2011. The rate of decline in smoking has slowed down from 2003 to 2011 compared with 1997 to 2003. Note: Current cigarette use is defined as smoking on at least 1 day during the 30 days prior to the survey. Source: CDC. 2012. Adolescent and school health: Youth risk behavior survey fact sheets. http://www.cdc.gov/healthyyouth/yrbs/factsheets/index.htm.

Although the cigarette is the most prominent tobacco product on the market, the use of other tobacco and nicotine products, including cigars, snus, spit tobacco, dissolvable tobacco products, and the e-cigarette, may be increasing [11, 12]. The health consequences of many new alternative tobacco products have not been tested or monitored, and are thus unknown. A major concern is that they will extend tobacco dependence of people who smoke regularly through their use in locations or during times that smoking would otherwise not be possible, thereby blunting public health measures designed to encourage tobacco cessation. Ultimately, the public health effects of these products will depend not only on their physical and chemical characteristics, but also on how they are marketed by companies, regulated by the Food and Drug Administration (FDA), and used by consumers.

Increased consumption of cigars is being influenced by disparities in taxes among cigarettes, small cigars, and large cigars. By slightly increasing the weight of small cigars, tobacco manufacturers can take advantage of the preferential tax treatment afforded to products classified as large cigars. However, these cigars seem to be used functionally more like cigarettes than traditional large cigars [13].

Tobacco and Cancer

There is sufficient scientific evidence to causally link tobacco use to cancers at 18 different organ sites through a number of mechanisms [2, 14–17]. Tobacco use accounts for approximately 30% of all cancer deaths and approximately 80% of lung cancer deaths [2]. Lung cancer, for which smoking is the primary risk factor, is the leading cause of cancer death in both men and women, accounting for more cancer deaths than the next four cancers combined [2].

In addition, there is substantial evidence demonstrating that smoking is associated with poor outcomes in cancer patients. Table 1 provides a compilation of selected studies showing that current smoking in proximity to a cancer diagnosis increases cancer-related and noncancer-related mortality, increases cancer recurrence, increases treatment toxicity, increases risk of developing a second primary cancer, increases risk of noncancer-related comorbidity, and decreases quality of life in a diversity of cancer disease sites. The adverse effects of smoking on survival are noted by a number of studies through a variety of mechanisms [18–25]. Smoking is known to increase mortality due to vascular disease, heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, smoking-related cancers, and nonsmoking-related cancers [26]. Bittner et al. [27] in 2008 exemplify the importance of noncancer-related smoking effects: in 1,354 prostate cancer patients treated with brachytherapy, only 8.7% of total deaths were attributed to prostate cancer. In these prostate cancer patients, current smoking increased the risk of death from cardiovascular disease (RR 3.05), cancers other than prostate cancer (RR 4.09), and death from other causes (RR 5.52), suggesting that for prostate cancer patients smoking may play a bigger role in survival than the prostate cancer itself [27]. Smoking increases the risk of developing second primary cancers [28–31], and smoking may synergistically enhance the risk of second malignancy and comorbid disease associated with cytotoxic cancer treatments [30–33]. Smoking also increases the risk of complications from cancer treatment [21, 23, 34, 35], decreases compliance with cancer-related therapeutics [36], and decreases quality of life in cancer patients and/or caregivers [37, 38]. Interestingly, studies suggest that between 30% and 40% of cancer patients who smoke may under-represent tobacco use by self-report [39, 40], suggesting that the observed effects of smoking may be underestimated. For example, Marin et al. [41] in 2008 demonstrated that self-reported current smoking had no significant effect on wound healing in head/neck cancer patients, but biochemically confirmed tobacco use with serum cotinine significantly predicted poor surgical outcomes. Recent studies have developed prognostic algorithms for smoking in head and neck cancer patients [42], and others have extended evidence to suggest that smoking be considered as a new standard part of cancer staging [43], which may be important considerations given the broad diversity of effects due to smoking.

Table 1.

Selected studies on the effects of smoking in cancer patients

Smoking increases the risk of developing second primary cancers, and smoking may synergistically enhance the risk of second malignancy and comorbid disease associated with cytotoxic cancer treatments. Smoking also increases the risk of complications from cancer treatment, decreases compliance with cancer-related therapeutics, and decreases quality of life in cancer patients and/or caregivers.

Relatively few studies have evaluated the effect of smoking cessation on outcome, but these limited studies suggest that continued smoking after diagnosis may worsen outcome and that tobacco cessation may reverse the adverse effects of smoking in cancer patients [44]. Phipps et al. [45] in 2011 reported on 2,264 colorectal cancer patients interviewed a median of 6.9 months after diagnosis, demonstrating that smoking increased cause-specific and overall mortality with higher risks in patients who continued to smoke at the time of interview. Browman et al. [46] in 1993 demonstrated that smoking during radiotherapy decreases overall and disease-free survival, but quitting within 12 weeks of diagnosis resulted in improved survival. In 1,416 prostate cancer patients treated with radical prostatectomy, smoking within 5 years prior to surgery increased risk of diagnosis at a younger age, advanced stage, and positive surgical margins; however, only persistent smoking 1 year after surgery was associated with increased recurrence [47]. A study by Bjarnason et al. [48] in 2009 evaluated 205 head/neck cancer patients treated with radiotherapy, demonstrating that patients who smoked during radiotherapy and who were treated in the morning had decreased severe mucositis than smoking patients treated in the afternoon (42.9% vs. 72%, p = .024), suggesting that some of the adverse effects of smoking may be acutely reversible. Unfortunately, there are no large randomized studies evaluating the effect of tobacco cessation on outcomes for cancer patients, but data support tobacco cessation at or following diagnosis as a potentially useful mechanism to improve cancer treatment outcomes and survival.

Despite this evidence of worse outcomes, a sizable portion of patients with cancer—as well as their families—continue to smoke after a cancer diagnosis [49–54]. Although many individuals are willing to try to quit, nicotine is highly addictive and overall success in quitting is relatively low [55, 56]. This may be due in part to the fact that many tobacco users do not utilize evidence-based approaches for tobacco cessation (i.e., formal smoking cessation support combined with pharmacotherapy) or do not receive sufficient support or referrals from their clinicians [55, 56].

Tobacco Cessation Treatment

There is a strong evidence base for tobacco cessation treatment. The U.S. Public Health Service (PHS) clinical practice guideline on tobacco cessation is based on nearly 9,000 studies and 35 meta-analyses and demonstrates that tobacco cessation treatments are effective across a wide range of populations [56]. Among the actions recommended by the guideline are the use of seven FDA-approved first-line medications and tobacco cessation counseling. Combining tobacco cessation medications, as well as tailoring medications to individual patient preferences, can be effective strategies to improve quitting success. The guideline also found that spending more time counseling patients led to higher quit rates. However, even group and telephone counseling, which are discussed below, are effective interventions, as well as brief interventions as short as 3 minutes.

Quitlines reach a broad population with evidence-based tobacco cessation counseling, education, and referrals. In the U.S., individuals can call into the national network of state quitlines at 1-800-QUIT-NOW or visit http://www.smokefree.gov. Other partners in national tobacco control, including the American Cancer Society and Legacy, offer quitlines and online quitting resources, such as the EX Plan [57]. In addition, clinicians can provide tobacco cessation counseling and medication, or patients can be referred to tobacco cessation programs, in some cases, including inpatient treatment. The guideline recommends that all clinicians utilize the 5A’s approach for treating tobacco dependence, which includes asking patients about their tobacco use, advising patients to make a quit attempt, assessing the patient’s willingness to make a quit attempt, assisting in the quit attempt, and arranging follow-up to contact patients on their progress (Table 2). Alternatively, the “2A and R” approach can be used: Ask, Advise, and Refer to a separate cessation assistance program [58].

Table 2.

The 5A’s model for treating tobacco use and dependence

Despite the major health threat of tobacco use and the availability of evidence-based approaches for tobacco cessation, there are a number of barriers preventing widespread use of tobacco cessation treatment. Unfortunately, many clinicians—including primary care providers, nurses, and oncologists—are reluctant to identify and address tobacco use by their patients [56, 59, 60]. Oftentimes, patient tobacco use status is not assessed in clinician encounters, and many clinicians do not refer patients to cessation programs. Some clinicians may also be reluctant to treat a patient’s tobacco dependence if he or she is undergoing cancer treatment, although some cessation medications have been used for decades in cancer patients, and quitting smoking can have a marked effect on a patient’s survival. Involving a broad range of clinicians in the assessment and treatment of tobacco use is also important, as the more types of clinicians involved, the more likely the quitting success [56].

Importantly, there is a lack of accountability for assessing tobacco use in patients and providing associated cessation treatment—it is not a requirement for accreditation or for receiving a cancer center designation. A recent survey of National Cancer Institute-designated cancer centers found that only 62% of centers routinely provide tobacco education materials, and just more than half of centers reported effective identification of patient tobacco use; 20% of centers had no tobacco cessation services, and less than half of the cancer centers had personnel designated to provide tobacco cessation treatment [61].

Lastly, a lack of insurance coverage and other incentives prevents the use of tobacco cessation treatment; however, the Patient Protection and Affordable Care Act (ACA) will expand coverage for these services, as discussed below.

Importantly, there is a lack of accountability for assessing tobacco use in patients and providing associated cessation treatment—it is not a requirement for accreditation or for receiving a cancer center designation. A recent survey of National Cancer Institute-designated cancer centers found that only 62% of centers routinely provide tobacco education materials, and just more than half of centers reported effective identification of patient tobacco use; 20% of centers had no tobacco cessation services, and less than half of the cancer centers had personnel designated to provide tobacco cessation treatment.

Tobacco Control Policy, Advocacy, and Education

In addition to recognizing and treating tobacco dependence as a serious medical problem, strong tobacco control policy, advocacy, and education are also needed to confront the population health consequences of tobacco use, as well as those impacting cancer patients who use tobacco.

Federal and State Tobacco Policy

In 2010, the federal government launched a national strategic action plan, Ending the Tobacco Epidemic, to coordinate tobacco control activities [62]. The Centers for Disease Control and Prevention (CDC) is the lead agency for comprehensive tobacco prevention and control, but tobacco control efforts also involve FDA, Centers for Medicare and Medicaid Services, and other agencies. CDC supports state tobacco control efforts by providing funding for infrastructure and training, running antismoking media campaigns, and helping support the national network of state quitlines.

The Family Smoking Prevention and Tobacco Control Act (Public Law 111-31), passed in 2009, provides FDA with the authority to regulate the manufacture, distribution, and marketing of tobacco products to protect public health. One of the provisions of the Act was to require larger, more prominent health warnings for cigarettes. These graphic warning labels have been challenged in the courts by the tobacco industry, and the warnings as promulgated were deemed unconstitutional by the U.S. Court of Appeals for the District of Columbia Circuit [63]. In March 2013, FDA dropped its legal fight over the graphic warning labels and will instead propose new cigarette warning labels [64].

The ACA expands the coverage for tobacco cessation treatment. New private health insurance plans must provide beneficiaries with high-value preventive services that receive an “A” or “B” rating from the U.S. Preventive Services Taskforce at no cost to plan members, which includes tobacco cessation treatment. The ACA also calls for coverage of tobacco cessation treatment for pregnant women in Medicaid without cost sharing, and in 2014 will forbid state Medicaid programs from excluding coverage of tobacco cessation medication for all beneficiaries [65]. When states created their essential health benefits packages established by the ACA, the U.S. Department of Health and Human Services suggested that states look to the Federal Employee Health Benefits Plan, which started covering comprehensive tobacco cessation treatment as part of its national strategic action plan on tobacco.

In addition to federal efforts, states are undertaking a number of strategies to reduce tobacco use, including smoke-free environments and taxes. Tobacco control efforts in three states—California, New York, and Massachusetts—were featured at the workshop. California reduced the incidence of lung and bronchus cancers by nearly 30% between 1988 and 2009 (Fig. 2A), about twice the decline in the rest of the U.S., attributing much of that decline to state policies and educational efforts aimed at changing social norms for tobacco. The state and city of New York have passed laws mandating smoke-free workplaces and public places and increased funding for tobacco prevention and cessation programs that contributed to a 50% decline in the rate of youth smoking and a 19% decline in adult smoking from 2002 to 2007 (Fig. 2B) [66, 67]. By providing tobacco cessation treatment benefits to its Medicaid beneficiaries, Massachusetts has dramatically decreased tobacco use and has documented a 46% drop in annual hospital claims for heart attacks among Massachusetts Medicaid beneficiaries [68]. Researchers found that the tobacco cessation benefit has an estimated return on investment of $2.12 for every dollar spent on program costs [69].

Figure 2.

Impact of tobacco control measures in California and New York City. (A): With a 15-year investment of $1.8 billion in tobacco control, lung and bronchus cancer incidence rates declined faster in California compared with the rest of the U.S. from 1988 to 2009. Source: California Department of Public Health, California Tobacco Control Program. (B): Impact of tobacco taxes and smoke-free laws on adult and youth smoking prevalence in New York City, 2002–2006. Source: Ellis et al. [66]; New York City Department of Health and Mental Hygiene [67].

Advocacy and Education

Advocacy and education are important contributions to advancing tobacco control policies, preventing tobacco use, and promoting cessation. The tobacco industry has been incredibly effective at encouraging smoking through its advertising and promotions [70]. However, extensive evidence illustrates that antitobacco media campaigns are an effective mechanism to discourage tobacco use [70–74]. For example, more than one-fifth of the decline in youth smoking that occurred from 1999 to 2002 could be attributed to the Legacy truth campaign [75]. CDC’s media campaign, Tips from Former Smokers, was linked to a doubling of calls to quitlines and a tripling of unique visits to the website. With the evolving modes of communication and entertainment, tobacco education efforts are also expanding to the Internet, cell phone apps, social networking sites, video game kiosks, and computer tablets [76–79].

The involvement of clinicians, clinician organizations, businesses, and patients in promoting tobacco control is also critical. Although a number of oncology organizations have issued supportive statements, tobacco cessation treatment is not part of standard cancer care [80–83], and many workshop participants stressed that more could be done to advance tobacco control efforts and more widely promote tobacco cessation treatment in the cancer care community. To promote cancer risk reduction, C-Change encourages clinicians, businesses, and cancer centers to become leaders in tobacco control advocacy within their own communities [84].

Challenges to Advancing Tobacco Control

A number of challenges hamper tobacco control efforts, including actions by the tobacco industry to continue to undermine effective tobacco control strategies, such as media campaigns to oppose tobacco tax increases and legal challenges at the local, state, and federal levels. Defending legal challenges brought by the tobacco industry can be financially insurmountable, especially for small communities. A major problem is the extreme asymmetry of tobacco industry funding compared with the amount of public health funding allocated to tobacco control, with the tobacco industry outspending state tobacco prevention efforts by 23 to 1 [85]. In addition, because of budget pressures, state funding for tobacco control programs, approximately $500 million, is far below the CDC-recommended spending level of $3.7 billion and has been declining in recent years [86, 87].

Moving Forward

Workshop participants suggested a number of potential high-value strategies to (a) integrate tobacco assessment and cessation treatment in clinical practice; (b) facilitate access to and use of tobacco cessation treatment; (c) advance tobacco control advocacy and policy; and (d) leverage research to improve tobacco control.

Integrating Tobacco Assessment and Cessation Treatment in Clinical Practice

Clinicians play a vital role in reducing the burden of tobacco-related cancers by recognizing and treating nicotine dependence as a serious chronic medical condition that influences both the development of cancer and the outcomes of cancer treatment. Clinicians can make substantial contributions to reducing tobacco-related health burdens by incorporating tobacco assessment and cessation support as a standard part of clinical care for all patients. This includes discussing the health consequences of ongoing tobacco use and the health benefits associated with cessation, providing consistent and repeated counseling for tobacco cessation, and recommending or providing evidence-based counseling and medication for all patients who use tobacco at every patient encounter.

Cancer care could be improved by accurately identifying tobacco use in cancer patients during and following cancer treatment using structured tobacco assessments and/or biochemical confirmation methods. To improve treatment outcomes and reduce cancer treatment toxicity and complications, oncologists can incorporate tobacco cessation treatment as the standard of care for all patients who use tobacco products. This change could be rapidly implemented by mandating that all institutions treating cancer patients must have or refer patients to evidence-based tobacco cessation treatment as a requirement for Commission on Cancer accreditation or for designation as a National Cancer Institute cancer center or comprehensive cancer center, and by asking other accrediting bodies to do the same.

Facilitating Access to and Use of Tobacco Cessation Treatment

Several changes could facilitate access to and advance tobacco cessation treatment. Payment incentives could encourage clinicians to assess tobacco use and refer to cessation treatment. Assessment and referral could also be mandated as a condition of reimbursement for standard medical procedures, such as a wellness office visit. Electronic medical records (EMRs) could facilitate tobacco assessment, cessation referrals, and cessation treatment, but not all EMRs have fields consistent with the PHS tobacco dependence treatment guideline [88]. Increased funding for tobacco cessation programs and enhanced training for health care professionals in providing evidence-based tobacco cessation treatment in a manner that personalizes treatment to prioritize patient preferences and needs would also be beneficial. Given the high return of investment for tobacco cessation treatment and programs [69], ensuring that all insurance plans provide coverage for evidence-based tobacco cessation treatment would also increase access. Enhancing coordination among health care systems and tobacco cessation treatment providers in the community, such as quitlines, may also expand referrals to tobacco cessation services.

Advancing Tobacco Control Advocacy and Policy

Tobacco control advocacy and policy could be improved through better coordination of institutional, local, state, and national tobacco control efforts and oversight. A major factor is ensuring that tobacco control programs have sufficient resources to achieve their missions. Additionally, ensuring that communities have the capacity to defend legal challenges from the tobacco industry is also critical. Engaging clinicians and national clinician societies to join with the public health community could also generate powerful synergies in promoting tobacco control measures. Tobacco control policy and advocacy efforts also need to rapidly adapt to the trends of tobacco marketing and product use, including the dual use of noncombustible and combustible products, as well as the use of new products (e.g., e-cigarettes).

Reductions in tobacco use could be achieved by using FDA regulatory authority to reduce the amount of nicotine in tobacco products to nonaddicting levels so that consumers who would like to discontinue use can do so more readily. In addition, enabling consumers to make informed decisions about tobacco product use could be accomplished by rapidly assessing and effectively communicating the relative health risks of new, combined, and alternative tobacco products, using evidence-based approaches with FDA oversight. Other strategies to reduce tobacco use include advancing effective policies and advocacy efforts, such as taxes, smoke-free laws, and media campaigns.

Leveraging Research to Improve Tobacco Control

The role for health research to improve tobacco cessation treatment and tobacco control efforts is also extensive. Improving the capacity for rapid research to assess the use and health effects of new tobacco products is needed, as well as providing more funding for research on lung cancer and tobacco cessation treatment. To better understand the impact of tobacco use and cessation on cancer treatment, all cancer clinical trials could include measures to assess tobacco use and cessation [59, 89]. In addition, research could maximize the impact of FDA oversight by informing product standards and other regulations. More research on effective communication strategies, including the roles of emerging social media and other communication innovations, to inform the public about the risks of tobacco use and to promote quitting attempts is also needed. Finally, prioritizing behavioral and social science research on tobacco use and cessation, along with interventional health research efforts, could also inform future tobacco control strategies and enhance the impact of tobacco cessation treatment that may ultimately reduce tobacco-related cancer incidence and mortality.

This article is available for continuing medical education credit at CME.TheOncologist.com.

Acknowledgments

The responsibility for the content of this article rests with the authors and does not necessarily represent the views of the Institute of Medicine, its committees, or its convening activities. The activities of the Institute of Medicine’s National Cancer Policy Forum are supported by its sponsoring members, which currently include the National Cancer Institute, Centers for Disease Control and Prevention, Association of American Cancer Institutes, American Association for Cancer Research, American Cancer Society, American Society of Clinical Oncology, American Society for Radiation Oncology, Bristol-Myers Squibb, C-Change, CEO Roundtable on Cancer, GlaxoSmithKline, LIVESTRONG Foundation, Novartis Oncology, Oncology Nursing Society, and Sanofi Oncology. We thank the speakers and participants for their contributions to the workshop.

Author Contributions

Conception/Design: Erin P. Balogh, Carolyn Dresler, Ellen R. Gritz, Thomas J. Kean, Sharyl J. Nass, Brenda Nevidjon, Benjamin A. Toll, Roy S. Herbst

Collection and/or assembly of data: Erin P. Balogh, Carolyn Dresler, Sharyl J. Nass, Benjamin A. Toll, Graham W. Warren, Roy S. Herbst

Data analysis and interpretation: Erin P. Balogh, Carolyn Dresler, Mark E. Fleury, Matthew L. Myers, Benjamin A. Toll, Roy S. Herbst

Manuscript writing: Erin P. Balogh, Carolyn Dresler, Mark E. Fleury, Ellen R. Gritz, Thomas J. Kean, Matthew L. Myers, Sharyl J. Nass, Brenda Nevidjon, Benjamin A. Toll, Graham W. Warren, Roy S. Herbst

Final approval of manuscript: Erin P. Balogh, Carolyn Dresler, Mark E. Fleury, Ellen R. Gritz, Thomas J. Kean, Matthew L. Myers, Sharyl J. Nass, Brenda Nevidjon, Benjamin A. Toll, Graham W. Warren, Roy S. Herbst

Disclosures

Benjamin A. Toll: Pfizer (RF); Matthew Myers: California Light Cigarette Class Action Case (ET). The other authors indicated no financial relationships.

Section Editor: Powel Brown: None.

Reviewer “A”: None

(C/A) Consulting/advisory relationship; (ET) Expert testimony; (RF) Research funding; (E) Employment; (H) Honoraria received; (OI) Ownership interests; (IP) Intellectual property rights/inventor/patent holder; (SAB) Scientific advisory board