Primary care role in cancer prevention

Linda Bauld, University of Edinburgh &

Cancer Research UK

@LindaBauld

Outline• Cancer prevention

• Main preventable risk factors

• Interventions• At the population level• At the individual level

• Vaping

15.1%

6.3%

3.8%

3.8%

3.6%

3.3%

3.3%

1.9%

1.5%

1.0%

0.7%

0.5%

0.4%

Cancer Prevention Ambitions

1. Create a “tobacco free” UK by 2035 (less than 5% prevalence)

2. Stall and see a decline in the proportion of adults who are overweight and obese and see a significant decline in the proportion of children who are overweight and obese

3. Reduce overall consumption of alcohol with an emphasis on hazardous and harmful drinking

4. Stall or reduce the incidence of melanoma, through limiting harmful UV radiation exposure

Prevent

• Tobacco use is the leading preventable cause of cancer, accounting for 54,300 cases in the UK each year

• Smoking cessation is relevant for primary and secondary prevention

• Preventing smoking uptake is also important in reducing tobacco-related cancers in the future

Smoking and Cancer

Stop Smoking Services Slashed

• 31% of local authorities no longer have a specialist stop smoking service (as of January 2020)

• Local authority spending on SSS and tobacco control declined by 36% between 2014/15 & 2018/29

• In 23% of local authorities, GPs no longer prescribe NRT

• 3% of LAs have completely removed any provision – affecting at least 100,000 smokers

Source: https://ash.org.uk/information-and-resources/reports-submissions/reports/many-ways-forward/

Alcohol and Cancer

• Alcohol is responsible for around 11,900 cancers in the UK every year

• A large proportion of head and neck cancers are caused by alcohol – e.g. 30% of UK mouth cancers

• But because the underlying risk is higher, alcohol is responsible for more cases of breast and bowel cancer – a combined total of around 8,000 cases a year

Obesity and Cancer• Overweight and obesity is

responsible for around 22,800cancers in the UK every year

• A If current trends continue, it will lead to a further 670,000 cancer cases over the next 20 years.

• Overweight and obesity is linked to some of the most common types of cancer like breast and bowel cancer –and some of the hardest to treat like pancreatic and oesophageal cancer.

Trend in severe obesity among adultsHealth Survey for England 1993 to 2015 (three-year average)

Adult (aged 16+) severe obesity: BMI ≥ 40kg/m2

Obesity prevalence by deprivation decileNational Child Measurement Programme 2017/18

Patterns and trends in child obesity

Child obesity: BMI ≥ 95th centile of the UK90 growth reference

26.8%25.7%

23.8%

21.9%

20.0%18.5%

16.9%15.7%

14.0%

11.7%12.8%

12.0%11.0%

10.1%9.4%

8.5%7.8% 7.5%

6.8%5.7%

0%

5%

10%

15%

20%

25%

30%

Mostdeprived

Leastdeprived

Ob

es

ity

pre

vale

nc

e

Index of Multiple Deprivation 2015 decile

Year 6

Reception

Childhood Obesity

What can we do?

1. Raise Awareness

Raising awareness

• Cancer Research UK has been working to raise awareness of the links between preventable risk factors & cancer

• Understanding of the links between obesity and cancer, and alcohol and cancer, are low

• Surveys we have funded suggests (as in Australia and Canada) that individuals who know the links between alcohol and cancer and obesity and cancer are…

• More supportive of effective population level policies

• AIM: To measure public awareness of the link between obesity and cancer in the UK adult population

• METHODS: Online cross-sectional survey.3293 participants (adult, UK-wide)

• KEY FINDINGS: Low levels of awareness with only 1 in 4 linking obesity and cancer when unprompted

Obesity Awareness

What can we do?

1. Advocate for population level policies

Policy Environment: UK

The future of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all depend on a radical upgrade in prevention and public healthSimon Stevens “NHS Five Year Forward View”

Reformulation: creating a healthier food supply

70% reduction insaturated fat

7% reduction in energy

40% reduction in fat

50% decrease in salt

50% decrease in salt

30% less sugar

The in-store environment

Price• Health-related food taxes now in place

in France, Hungary, Finland, Norway, Mexico, some US states and some South Pacific islands (mostly sugary drinks)

• In Mexico a 10% tax on sugary drinks linked to ~ 10% decline in purchases

• Implementation of UK soft drink industry levy last year has prompted change– (i.e ‘Irn Bru’ reduced sugar content by 50%)

Food marketing to children increases energy intake, particularly amongst the obese

• Exposure to food advertisements increased subsequent energy intake in all children

• The increase was greater in obese children (155%) and the overweight children (101%) than the NW children (89%).

Source: Halford, Boyland, Hughes et al (2008) Pub Health Nutr. 11 (9), 897- 904

Open bars: Toy adverts; Shaded bars: Food adverts

Policy priorities

What can we do?

1. Support individuals in primary care

• Advice increases quit attempts by 24%

• Offering support on how to quit

increases them by 68% to 117%

• Direct comparison offer help vs offer

advice increases quit attempts by 39%

to 69%

Brief Advice

Conclusions of the BWeL trial

• Most patients find very brief interventions related to their excess body weight very acceptable

• 1 in 500 people find it unacceptable and unhelpful

• No one found it very unacceptable and very unhelpful

• A very brief intervention of offering help, immediate booking, and creating accountability can motivate over 40% of unselected patients to attend a weight management programme

• This intervention could reduce the weight of the population of people who are obese by 1.5-2.5kg.

Vaping

Prevalence of vaping and heat not burn use

N=125,758 adults from Nov 2013 (E-cig); N=30,957 adults from Aug 2018 (Juul); N=63,499 adults from Jan 2017 (HNB: heat-not-burn)

Source: www.smokinginengland.info/latest-statistics

0

5

10

15

20Pe

rcen

t

E-cig

Juul

HNB

Use in smokers and recent ex-smokers

N=34602 adults who smoke or who stopped in the past year (N=11217 asked about HNB; N=5256 asked about Juul)

Source: www.smokinginengland.info/latest-statistics

0

5

10

15

20

25

30

35

40

45

50Pe

rcen

to

f sm

oke

rs a

nd

rec

ent

ex-s

mo

kers Any E-cig

Daily E-cig

Juul

HNB

Prevalence of nicotine use: never & long-term ex-smokers

N=101641 never and long-term ex-smokers from Nov 2013 Source: www.smokinginengland.info/latest-statistics

0

5

10

15

Perc

ent

Never: E-cigs

Long-term ex: E-cigs

Never: NRT

Long-term ex: NRT

Source: Bauld, L, MacKintosh, A, Eastwood, B, Ford, A, Moore, G, Dockrell, M, Arnott, D, Cheeseman, H, McNeill, A. (2017) Int. J. Environ. Res. Public Health, 14, 973; doi:10.3390/ijerph14090973

Surveys including over 60,000 young people: Regular e-cigarette use is confined to those who have smoked

Source: ASH Smokefree GB youth survey 2015 and 2019 11-18 year olds

Source: ASH Smokefree GB youth survey 2015 and 2019 11-18 year olds

What about safety?

As of Jan 14th, 2020 2,668 cases of EVALI have been reported in the USA. There have been 60 deaths in 27 states, primarily in youngadults.

After several months of little clarity,CDC investigations now clearly showthat the vast majority of cases involve THC vaping, using illicit products contaminated withVitamin E acetate.

There are 10 million vapers in theUSA, e-cigarettes available for 10years with no cases like this previously. Early CDC advice was not to vape. Now it is not to vapeTHC products particularly illictproducts.

No similar proven cases in the UK. Vitamins & THC are illegal in vaping here and the market more tightly regulated.

Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and NRT Users

The research team: Lion Shahab, Maciej L. Goniewicz, Benjamin C. Blount, Jamie

Brown, Ann McNeill, K. Udeni Alwis, June Feng, Lanqing Wang, Robert West Published

in Annals of Internal Medicine 7th Feb 2017 Funded by Cancer Research UK

5. Study results

*Adjusted for socio-demographic, physical and mental health characteristics and latency to product use

0

50

100

150

200

250

NRT Only EC Only NRT+Cig EC+Cig

% o

f ci

gare

tte

-on

ly s

mo

ker

leve

ls*

Total nicotine equivalents (95% CI)

Nicotine metabolites

0

20

40

60

80

100

120

140

NRT Only EC Only NRT+Cig EC+Cig

% o

f ci

gare

tte

-on

ly s

mo

ker

leve

ls*NNK (NNAL) (95% CI)

5. Study results

*Adjusted for socio-demographic, physical and mental

health characteristics and latency to product use

97.5%

Nitrosamines

0

20

40

60

80

100

120

140

160

180

NRT Only EC Only NRT+Cig EC+Cig

% o

f ci

gare

tte

-on

ly s

mo

ker

leve

ls*

Acrolein (3-HPMA) (95% CI)

• Significant reduction in NRT/EC-only users compared with cigarette smokers (even greater reductions for Acrylonitrile & Butadiene)

5. Study resultsSelected toxic volatile organic compounds

*Adjusted for socio-demographic, physical and

mental health characteristics and latency to

product use

66.6%

Key Findings• Current E-cigarettes are good nicotine delivery devices, likely to be effective for

helping people stop smoking

• Long-term use of e-cigarettes only is associated with reduced exposure to known smoking-related toxicants/carcinogens

• Intake similar to NRT, a safe product > likely to result in significantly reduced cancer (health) risks long-term

• Dual use of e-cigarettes or NRT with combustible cigarettes does not appreciably reduce exposure to known smoking-related toxicants/carcinogens

• Long-term health benefits of e-cigarette use only likely following complete cessation of combustible cigarettes

Very New Study – Cardiovascular effectsBHF Funded, led by Professor Jacob George, University of Dundee

Smokers randomised to EC with nicotine or without nicotinefor one month. Parallel non randomised preference group of continuing smokers.

Both the nicotine and non nicotine EC groups showed significant improvement in vascular health

Consensus that vaping is significantly less harmful than smoking

• England, key organisations 2015

• Followed by BMA report (2017) reflecting the consensus

• Scotland 2017

Aids used in most recent attempt to stop smoking

N=15530 adults who smoke and tried to stop or who stopped in the past year; method is coded as any (not exclusive) use; N=4155 adults asked on HNB and N=1480 on Juul

0

5

10

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25

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50Pe

rcen

to

f sm

oke

rs t

ryin

g to

sto

p

E-cigs

NRT OTC

NRT Rx

Champix

Beh'l supp

HNB

Juul

The TEC Trial: Recent large RCT

• Funded by NIHR and CRUK

• 886 adults randomised to either combination NRT or EC, plus stop smoking service support

• Results endorse UK approach to support EC use in general adult population of smokers trying to quit

Procedures, NRT & EC

• Product use started at the TQD session

• Participants committed to using allocated product for at least 4 weeks

• Weekly support sessions as per usual practice

• Followed up at 6 and 12 months

• If abstinence reported at 12M, participants invited for CO reading and paid £20 for travel and time

• 88% used combination therapy (typically patch + faster acting product)

• Free to switch NRT products - 59% switched

• Supplies for three months

• Cost to NHS: £120 for 3M of one product

• EC Starter pack ‘One Kit’ (with adapter, spare battery, 5 atomisers), 30ml bottle of tobacco flavour e-liquid (18mg/ml nicotine)

• Cost: £30.25

Effects on abstinence & reduction at 1 yearEC (N=438) NRT

(N=446)RR (95% CI)

% abstinent* for 52 weeks

18.1% 9.9% 1.83 (1.30 to 2.58)

Results similar for a range of sensitivity analyses and secondary outcomes

CO validated reduction in non-abstainers

12.8% 7.4% 1.75 (1.12 to 2.72)

*biochemically validated

High on-going EC use in abstainers

• At one year, 9% in NRT arm still on NRT, 80% in EC arm still on EC (about a third of them using nicotine free EC)

• Bad if it poses health risks later on

• Good if it prevents relapse (as long-term NRT use), reduces discomfort and weight gain, maintains smoking rewards

• Trial team have ethical approval to continue to follow up participants

The evidence so far….

• Vaping is far less harmful than smoking

• Vaping can help people stop smoking

• No gateway effect in the UK

• Your patients who smoke may not know this, and 35% of smokers in Great Britain have never tried vaping

Harm Perceptions

7%

15%

22%

25%

26%

25%

26%

22%

35%

34%

33%

30%

33%

30%

21%

17%

19%

15%

13%

17%

15%

10%

2%

2%

1%

1%

1%

1%

39%

30%

23%

28%

29%

23%

27%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

2013

2014

2015

2016

2017

2018

2019

Perceived harm of e-cigarettes relative to cigarettes

More or equally harmful Less harmful A lot less harmful Completely harmless Don't know

For further advice

CRUK and RCGP video + podcast on e-cigarettes, August 2018

• E-cigarettes – RCGP podcast1 and video2:

• Suitable for the busy GP – 10 minutes long

• Addresses key concerns around safety, passive vaping and entry into smoking

• Webinar3 – Smoking cessation: Why and how to support your patients to stop smoking (when time and funding are against us!)

• Suitable for the busy GP – 20 minutes long

• Addresses current smoking cessation strategies available to GPs

• E-learning modules– VBA and Smoking cessation

• Behaviour change and cancer prevention

• Essentials of smoking cessation

• 30 minutes each, offering practical support

• RCGP Position Statement on e-cigarettes

Primary care & cancer matters online learning

Thank You

Linda.Bauld@ed.ac.uk

@LindaBauld