Cancer Survivors urged never to start smoking because of heightened risk of secondary cancer
Posted by Bronwen Maher on November 28, 2011 at 03:22 PM
Nessa Childers MEP
'Saving lives a second time'
Speech delivered to the ‘Irish Conference on Survivorship after Cancer during Childhood and Adolescence’, held on November 26 2011
Introduction
Fellow speakers and distinguished guests- as a politician, it's not often I'm able to stand in a room and feel that most of the people I'm speaking with are in broad agreement on an issue, so this is a privilege.
We're all here today with the single purpose of saving lives. Most of us dedicate ourselves to this professionally on a daily basis. Specifically, I'm going to speak about preventing secondary cancers in child-hood cancer survivors, by persuading them not to smoke. So, distinguished collegues, I hope you'll forgive me if I skip ahead a bit today and concentrate on saving lives a second time around.
As a psycho-analyst of over 20 years experience- before I entered politics full-time in 2009- I would also like to concentrate on the mental aspects of a child's recovery from cancer. This will include what this can mean for their susceptibility to smoking and other behavioural actions which would expose them to a second cancer later in life.
Having cancer as a child and what that means
Smoking among cancer survivors is a complicated, emotive subject, and one which in many respects cannot be trivialised through a list of statistics or a single speech.
To understand its proper context, the children's wards in Crumlin, Temple St and Tallaght Children's Hospitals must first be considered.
Thankfully, we are lucky in that 80% of those suffering from childhood cancer will survive, and most go on to live full and happy lives. The flipside of this is that about ¾ of survivors experience some long-term implications. These may include second cancers, cardiac disease, infertility and early menopause, liver, kidney and bone problems, and cognitive deficits, especially in children who were treated for brain tumours.
Furthermore, the treatments which children with cancer recieve, while visionary and life-saving, are also harsh, particularly on bodies which are still developing. The particular radiotherapy regimes and chemotherapy drugs used to treat children with Hodgkin's lymphoma, soft tissue sarcomas or Wilms' tumour, in particular, are known to put these children at an increased risk of developing further new cancers than most other childhood survivors.
The end result is a sevenfold excess of all cancers after childhood cancer. Health-related adverse behaviours, like cigarette smoking, can promote or exacerbate these long-term vulnerabilities.
The relationship between smoking and cancer as a child
There are needless to say, many, obvious connections between smoking cigarettes and an increased risk of second cancers for child-hood survivors.
Survivors of childhood cancer are particularly vulnerable to tobacco-related health problems because they may have reduced pulmonary function, and are also at a possible risk for congestive heart failure as a result of the treatment they recieved.
Cigarette smoking, which slows lung growth in normal adolescents and is an independent risk factor for heart disease in adulthood, would further compound these predispositions.
In adults, cigarette smoking has been associated with the development of second cancers for a variety of cancer diagnoses, such as head and neck cancers, Hodgkin’s disease, and bladder cancer.
And these are just the physical effects- While a notable aspect of childhood sufferers of cancer is their generally sunny disposition during treatment, psychological scars of their battles often come, and stay with many survivors for the rest of their lives.
This is something which I will continue to touch on later in my speech. Although many survivors of childhood cancer have levels of social competence and adjustment similar to those of their peers who have not had cancer, a vulnerable subset will suffer from more psychological and behavioural problems.
How common is smoking among childhood cancer survivors?
So, how prevalent is smoking among survivors of child-hood cancer? Thankfully, all of the studies carried out on this topic seem to say the same thing- Overall, a smaller proportion of childhood cancer survivors smoke than in the general population.
To the ongoing credit of doctors and health professionals who pursue this outcome, this has undoubtedly saved lives.
While in previous decades childhood cancer survivors smoked at rates similar to the rest of the population, the smoking rate in more recent years has declined significantly among survivors.
Survivors are less likely to have ever smoked (23.0% versus 35.7%), less likely to become regular smokers (19.1% versus 31.3%), and are also less likely to experiment with occasional cigarette smoking, so in many ways the current approach is working.
But is there more that we can do? Of course....
The flipside of these statistics is that as high as 20% of childhood cancer survivors are still smoking currently. Furthermore, survivors are less likely to quit smoking, when compared to their peers, by a considerable margin (26.6% versus 35.2%).
It is predictable that older subjects are those most likely to have ever smoked and thus are more likely to ever become regular smokers. However the statistics are also worryingly high among those who never attended third-level education.
What can we do?
What can we do, as health professionals, stake holders and legislators, to continue to drive down these statistics?
Well, as we are all aware, different people react in different ways. It sounds like an obvious statement but it's one that we should keep in mind at all times when setting out policy- whether it be to stop survivors from smoking or persuading them to give up. Whatever direction we take, the golden rule should be that it's not one-size fits all.
If a normal smoker asked a clinic for advice on how to give up, they would be given several options- a councillor-ed approach or a self-paced initiative, and so on. When dealing with the complicated issue of a cancer survivor, more targeted yet similar options need to be provided.
However it's also important to consider the statistics on each individual approach- In an American context, a 2005 study by Harvard School of Public Health showed that the quit rate was significantly higher in the counselling group compared with the self-help group at both the 8-month and 12-month follow-ups. The intervention group was twice as likely to quit smoking, compared with the self-help group, while smoking cessation rate increased with an increase in the number of counselling calls.
While the cost of delivering the intervention was approximately $300 per participant, when one continues the long term weight off the health system, 300 dollars per cancer survivor quitting is perhaps not a bad investment.
Legislating against smoking
How are legislators and politicians responding to this challenge?
Both in the EU and Ireland, important steps are being taken. As we all know, Ireland has an impressive record with regards to measures taken against smoking, and has often acted in tandem with other European countries.
Ireland's move in 2002 to ban smoking in the workplaces was seen as risky at the time, but has now been copied by 15 of Ireland's EU partners.
Ireland also, in 2009, became the first country in the EU to introduce a blanket ban on tobacco advertising at point-of-sale, and this decision has again been vindicated as it is copied around the world.
In Europe, the Commission took the decision in 2005 to ban tobacco advertising in all its forms, supplementing a 1991 directive which banned advertising in broadcast and print, which took in new forms of media such as the internet and also sports events like Formula 1.
This was despite the presence of a strong lobbying movement against the moves at the time- and this trend towards heavy corporate lobbying is prevalent whenever the EU makes moves which have a perceived strong corporate fall-out.
In 2003, the European Union halted the advertising of cigarettes as 'light' or 'mild', as they ruled that such wording had the potential to mislead the public about the dangers of tobacco.
Arguably, the key piece of EU legislation to tackle control of tobacco is the Directive on Tobacco Products and the Directive on Tobacco Advertising of 2001. The Directive set out two general warnings – "Smoking kills" and "Smoking seriously harms you and others around you", which must take up 30% of each packet of cigarettes in the EU.
Europe continues to work to reduce the exposure to smoking of all citizens, including of course child-hood cancer survivors. As an MEP on the European Parliament's Public Health Committee, I will play a central role in amending some important pieces of legislation which are currently coming down the track.
Next year, the European Commission is set to widen the scope of cigarette-trading rules to cover potentially harmful electronic cigarettes, flavourings and even marketing strategies, as part of a wider campaign to urge Europeans to quit.
Finally, campaigners such as myself continue to fight this battle on a more local level, both i Ireland and the EU. A few weeks ago I sent a letter, co-signed by 27 of my colleagues as well as leading industry representatives, NGOs, charities and researchers, to the European Commission on this subject. This letter demanded that the Commission proceed with no further delay on these legislative proposals on tobacco, and to issue a timetable for release of the proposals.
Persuasion
To go back to the message I introduced at the beginning as I attempt to wrap up my speech- A the end of the day, there is only so much structure that legislators, doctors, parents and friends can put in place- unless we take the final step of outright banning tobacco- which unfortunately won't be coming along at least for a while- the final decision is ultimately with the cancer survivor.
In this regard, it is important that the debate and the message are framed in the right way. As a cancer survivor, the message must be centred on control. Remember, control over their health is something they've lost so much of already- survivors will now want to claim as much control over their health as they possibly can. As such, we're not telling them to do something- or not to do something, as the case may be- we're saying 'This is the part over which you have control. The doctors, the politicians and the interest groups will leave you to it- you decide whether to put yourself at risk to a second cancer or not'.
The second part to this message is about the relationship a survivor will enter into with the tobacco industry if they become smokers- a kind of contract, if you will. Smokers tend to smoke more when they are under pressure, or feeling stressed, and as such if their health deteriorates they may find themselves becoming more and more dependent on tobacco. Our final message is simple- 'Don't become part of a vicious circle. Don't enter into this contract. Walk away, retain control'
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