ASCO发布烟草控制任务清单

美国肿瘤医生正在呼吁联邦和各州政府加强对烟草产品的监管，增加对研究的资助，以及确保新的医疗保险交易体系覆盖戒烟治疗。

根据美国临床肿瘤学会(ASCO)发布的政策声明，临床医生还应当“以身作则”地不吸烟，积极治疗烟草依赖，为无烟环境摇旗呐喊，以及拒绝接受烟草企业的支持。该声明发表在7月29日的《临床肿瘤杂志》上(doi:10.1200/JCO.2013.48.8932)。这是ASCO首次对2003年发布的烟草控制政策声明进行更新。



ASCO主席、纽约纪念Sloan-Kettering癌症中心的Clifford A. Hudis医生指出，本次声明提醒临床医生、政策制定者和公众，烟草戒断与控制的问题尚未得到解决。“尽管戒烟努力已在很多地区取得了成效，使得吸烟率明显下降，但仍有很多不尽人意之处，吸烟仍是美国的主要卫生保健风险之一，尤其是与癌症风险关系紧密。”

Hudis医生认为ASCO传递出的信息将会在国会山引起共鸣，在那儿，立法者们正在寻找具有成本效益的政策。“这是一个做正确的事情就能获得难以置信的回报的领域。”政府资助的研究就是一个这样的领域。ASCO正在争取政府对烟草控制相关研究的更大支持，涉及从吸烟机制到特定人群戒烟措施的一系列主题。ASCO还希望今后所有的肿瘤学临床试验都能将吸烟史作为一项核心数据元素。

ASCO还支持将戒烟治疗纳入保险覆盖范围，并增加对循证戒烟服务(例如强化咨询和使用已获准药物)的报酬。尽管Medicare和Medicaid均已覆盖戒烟治疗，但ASCO对于医疗保险交易体系的某些健康计划可能将戒烟服务排除在外的问题表示了担忧。

监管是ASCO官员呼吁采取更多行动的另一个领域。ASCO将会继续支持提高烟草产品价格的政策，以遏制吸烟和为烟草控制项目提供资金。ASCO认为所有的烟草产品都应当受到同样的监管，不能对雪茄烟网开一面。

该组织还对FDA烟草产品科学顾问委员会2011年提出的将薄荷烟撤市的建议表示了支持。FDA最近发表的一篇科学综述显示，薄荷烟可能与青少年和年轻成人开始吸烟的几率增加有关。在烟草中加入薄荷还可能与成瘾性增强有关，从而进一步增加戒烟难度。FDA官员总结认为，薄荷烟尽管并不增加毒性，但可能比非薄荷烟带来更大的公共卫生风险。FDA正在就如何监管薄荷烟的问题向公众征求意见。ASCO已启动了3项有关薄荷烟对公众健康影响及其与普通烟草比较的研究。这3项研究将分别探讨对薄荷烟的味知觉是否存在遗传差异，比较薄荷烟与非薄荷烟中的毒素和致癌物，以及分析薄荷对成瘾性的影响。

《肿瘤学实践杂志》7月29日发表的一项调查结果显示，肿瘤医生并未在临床实践中全力推动戒烟(doi:10.1200/JOP.2013.001025)。这项2012年针对ASCO会员的在线调查表明，在1,197名接受调查的肿瘤医生中，大约90%自称会在患者首次就诊时常规询问其吸烟情况，84%会建议患者戒烟。

但是在随访和提供治疗建议时，情况就明显不那么乐观了。仅有44%的肿瘤医生常规与患者讨论戒烟药物选择，仅有39%会提供其他的戒烟支持。受访者认为，缺乏有关戒烟干预的培训和患者的抵触，是妨碍其提供戒烟服务的障碍之一。

Hudis医生表示，有时候戒烟问题会被忙碌的医生忽视。为此，ASCO打算协助开发一些可融入医务人员日常工作的戒烟工具和资源，并呼吁医疗培训和继续医学教育更加关注戒烟问题。

爱思唯尔版权所有  未经授权请勿转载

By: MARY ELLEN SCHNEIDER, Internal Medicine News Digital Network

U.S. oncologists are calling on federal and state officials to beef up the regulation of tobacco products, increase research funding, and ensure access to cessation treatments through the new state-based insurance exchanges.

Physicians also need to "lead by example" by not smoking, treating tobacco dependence aggressively, lobbying for tobacco-free environments, and refusing to accept tobacco industry support, according to a policy statement from the American Society of Clinical Oncology. The statement was published July 29 in the Journal of Clinical Oncology (doi:10.1200/JCO.2013.48.8932). This is the first time ASCO has updated its policy on tobacco control since 2003.

The latest report reminds physicians, policy makers, and the public that the problem of tobacco cessation and control is not solved, said Dr. Clifford A. Hudis, president of the American Society of Clinical Oncology.

"While smoking cessation efforts have been rewarded in many populations with falling rates of cigarette and tobacco use, that’s not been uniform," said Dr. Hudis of Memorial Sloan-Kettering Cancer Center in New York. "It remains a dominant health care risk in the U.S. and specifically a cancer risk,"

But Dr. Hudis said he thinks ASCO’s message will resonate on Capitol Hill where lawmakers are looking for cost-effective policies. "This is an area where doing the right thing could yield unbelievable dividends in terms of savings for the system," he said.

One of those areas is in federally sponsored research. ASCO is seeking an increased federal role in research on a range of tobacco control areas from understanding the mechanisms of tobacco use to implementing tobacco cessation in specific populations including cancer patients and survivors. ASCO also wants to see tobacco use history and status included as a core data element that is collected throughout oncology clinical trials.

ASCO also supports coverage of tobacco cessation treatment insurance coverage and increased physician payments for evidence-based tobacco cessation services, such as intensive counseling, and FDA-approved medications. Although Medicare and Medicaid both cover tobacco cessation treatments, the ASCO report expresses concerns that these services could be left out of some health plans in the state-based insurance exchanges. ASCO wants to ensure when states set their essential health benefit packages for policies sold in the exchanges that they include a range of evidence-based services and drug therapies for tobacco cessation that are consistent with the recommendations of the U.S. Preventive Services Task Force.

Regulation is another area where ASCO officials are calling for more action.

The organization continues to support policies to increase the price of tobacco products in an effort to curb use and fund state tobacco control programs, including quit lines and youth prevention programs. ASCO supports a "substantial" increase in tobacco excises taxes, the establishment of minimum price laws for cigarettes that counteract industry discounts, and an increase on retail licensing fees.

All tobacco products should be regulated in the same way, ASCO said, without exemptions for cigars and cigarillos.

The organization also supports the 2011 recommendation from the FDA Tobacco Products Scientific Advisory Committee to remove menthol cigarettes from the market.

The ASCO recommendations come on the heels of a new scientific review by the Food and Drug Administration that shows that menthol cigarettes is likely associated with increased smoking initiation by teens and young adults. Menthol use is also likely associated with greater addiction, making it harder to quit. FDA officials concluded that menthol cigarettes, while not more toxic, likely pose a greater public health risk than did nonmenthol cigarettes.

The FDA is asking the public to offer suggestions for how menthol in cigarettes could be regulated.

The agency has also commissioned additional studies on the public health impact of menthol cigarettes, compared with regular cigarettes. The three studies will look at whether genetic differences in taste perceptions for menthol cigarettes, compare the smoke-related toxins and carcinogens between menthol and nonmenthol cigarettes, and consider the impact of menthol compounds on addiction.

Physicians also have a role to play when it comes to encouraging patients to quit and lobbying lawmakers on smoking-related regulations.

"Physicians are just one part of this discussion, though we can be leaders and motivators more broadly in the population," Dr. Hudis said.

But a new survey published on July 29 in the Journal of Oncology Practice shows that oncologists aren’t fully promoting smoking cessation in their practices (doi:10.1200/JOP.2013.001025).

The online survey of ASCO members conducted in 2012 shows that the vast majority of oncologists are asking patients about tobacco use at least initially. About 90% of the 1,197 respondents said they routinely asked patients about tobacco use at the initial visit and 84% advised patients to stop using tobacco.

But there was a significant drop off when it came to following up with treatment options. Only 44% routinely discuss medication options and only 39% provide other cessation support. The respondents cited inadequate training in tobacco cessation interventions and patient resistance as some of the barriers.

Dr. Hudis said sometimes tobacco cessation falls through the cracks for busy physicians. "That just reminds us that everyone in health care is stretched these days, working hard and balancing priorities," he said. "We just have to make sure that this remains front and center."

For its part, ASCO plans to help develop cessation tools and resources for providers to integrate into their practices. ASCO is also calling for a stronger focus on tobacco cessation both in medical training and continuing medical education courses. The organization is encouraging credentialing organizations to include questions about tobacco-dependence treatment in their exams. ASCO plans to partner with the American Board of Internal Medicine to make sure there is tobacco cessation content in the oncology specialty training boards.