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ED12.06 Tobacco Control Policies in Latin America
S56
Fig 1. Trends of tax income, tobacco consumption and smoking rate in Japan.6-8
Keywords: evidence-based policy, health effects, summary report
ED12.06 Tobacco Control Policies in Latin America Nise Yamaguchi,1 Norma Pilnik,2 Jaime De La Garza,3 Luis Ashton,4 Abel Garcia,5 Eduardo Bianco,6 Gregorio Kevorkof 7 1Clinical Oncology and Tumor Immunology, Hospital Albert Einstein, São Paulo/Brazil, 2 Internal Medicine Oncology Department, School of Medicine Cordoba University, Cordoba/Argentina, 3 Thoracic Oncology Unit and Laboratory of Personalized Medicine, National Cancer Institute, Mexico City/Mexico, 4 Auna, Lima/Peru, 5Cancer Prevention and Control, National Institute of Neoplastic Diseases, Lima/Peru, 6 Tobacco Epidemic Center, Montevideo/Uruguay, 7 Internal Medicine, National University of Cordoba, Cordoba/Argentina Introduction: Smoking is the single most important cancer risk factor and accounts for 26% of all cancer deaths and 84% of lung cancer deaths in Latin America.1 Lung cancer is one of the most preventable cancer types; and doctors of all expertise are essential to impart to patients and their families the idea of smoking prevention, thereby contributing to the reduction of mortality from lung cancer. There are around 145 million smokers age 15 years or older in Latin American. Adult smoking prevalence varies from 35% in Chile and 30% in Bolivia to 11% in Panama and 11. 7% in El Salvador.2,3 The continuing popularity of smoking among adolescents is particularly worrisome as smoking rates among teens and young adults predict future lung cancer rates.
Journal of Thoracic Oncology
Vol. 12 No. 1S
Smoking rates among young people aged 13e15 years are now higher than in adults in many Latin American countries. Prevalence among female adolescents has surpassed their male counterparts in Argentina, Brazil, Chile, Mexico, and Uruguay. Unless these high rates of smoking are curtailed, cancer mortality rates will continue to rise.3 We have assessed the impact on smoking rates of anti-tobacco policies adopted by five Latin American countries, in compliance to the WHO’s Framework Convention on Tobacco Control (FCTC). Argentina, Brazil, Mexico, Peru, and Uruguay were used as case studies to illustrate the challenges and ways in which governments and civil society organizations can effectively work together to reduce lung cancer deaths and other tobacco-related diseases. Since the endeavor for approving anti-tobacco policies was met with a strong lobby against it in these countries, different degrees of compliance with the FCTC terms were reached. We analyzed reports issued by local governments and epidemiologic surveys found in the literature. Tobacco farming in Latin-America has increased in recent years, representing almost 16% of the global production. Argentina and Brazil are among the ten largest world producers and the cultivated area in Latin America reaches 13.55% of the global land dedicated to tobacco farming worldwide. The prices paid by the tobacco industry to farmers are also increasing since 2007, and the sector employs 650,000 people. Tobacco farming is also present in Colombia, Dominican Republic, Honduras, Ecuador, Guatemala, Mexico, Nicaragua and Paraguay.4 Therefore, tobacco control policies must necessarily include solutions to help tobacco growers to escape from the influence of the tobacco industry without loss of income and jobs. Results: We have found a differential decrease (and increase) in smoking among the population of the studied countries in the last decades: Argentina: (from 29% in 2007 to 22.1% in 2014); Brazil (from 34.8% in 1989 to 14.7% in 2013); Mexico (21.7% in 2008-2011 to 23.6% in 2014); Peru (from 44.5% in 1998 to 21.1% in 2010 and 13.3% in 2013); Uruguay (from 34% in 1998 to 23.5% in 2011).5e11 Discussion: According to the 2014 FCTC Progress Report12, the implementation degree of the articles among the countries varied from <20% to more than >75% in most cases. One-third of all FCTC signing countries have not enacted anti-tobacco legislation or reached the full implementation of at least two important time-bound articles: tobacco advertising ban and health warnings on cigarette packages and at the selling points. Our data also showed uneven degrees of implementation among the studied countries. One of
January 2017
the underlying causes for slow implementation in some countries, like Mexico and Argentina, is the strong political lobby by the tobacco industry. In our study, Argentina has come in third in smoking prevalence, with a 22.1% smoking rate among adults, due to the strong pressure upon legislators by the tobacco industry that so far has prevented the FCTC ratification by the Congress. Nevertheless, the Argentinean political environment was more sensitive than the Mexican, to the persistent anti-smoking advocacy by the medical associations and organizations of the civil society. Therefore, some of the FCTC tobacco control policies were enacted by legislators in 2011 and implemented in 2013. Mexico, however, was the one with the poorest implementation of tobacco control policies and the highest in smoking prevalence among adults (23,60%), seconded by Uruguay (23.5%), where the past administration has neither enforced the already existing tobacco-control policies, nor promoted new ones, such as heavy taxes upon tobacco products. One of the important measures recommended by the FCTC — which has proved to be effective in smoking prevention among children and teenagers — is high taxation (over 75%) of tobacco products.12 Conclusion: The degree of compliance with the terms of the Convention seems to have a direct impact on the reduction of smoking rates in the countries studied. Other solutions should contemplate tobacco farmers, whose fear of shifting to new unfamiliar cultures is exploited by the tobacco industry to prevent FCTC ratification in many countries. But farmers should not stop growing tobacco plants, but just shift to transgenic tobacco farming13. Transgenic tobacco is being successfully tested for expression of for more than fifteen human therapeutic proteins, including antibodies, antigens for vaccines, and autoimmune inhibitor factors.(14-17) Pharmaceutical companies could benefit from the existing agricultural tradition of tobacco farming in Brazil, Argentina, and elsewhere by fostering the commercial production of those molecules. Transgenic tobacco is improper for smoking and could also have the nicotine gene knocked out to discourage misuse. Therefore, the pharma industry could open new roads to smoking eradication while preserving the economic activity and profitability of traditional tobacco farmers. Effective tobacco control requires a close cooperation between health institutions, medical societies, NGOs, and the press - and the regular funding of surveillance programs and educational campaigns. Smoking prevention programs must be part of the educational curricula from the pre-school onwards. Keywords: anti-smoking policies, smoking rates, biofarming, Tobacco Control
Abstracts
S57
ED13.02 Tissue-Based Biomarkers Glen Reid,1 Steven Kao,2 Nico Van Zandwijk1 Asbestos Diseases Research Institute, Sydney/Australia, 2 Medical Oncology, Chris O’Brien Lifehouse, Sydney/Australia
1
Introduction: Malignant pleural mesothelioma (MPM) is difficult to diagnose and accurate prediction of patient outcomes still relies on a range of clinical scores. Despite extensive efforts in the last decade, there are few tumorbased molecular markers that can accurately contribute to diagnosis and prediction of disease course. Recent reports describing the mutational and transcriptional landscape of MPM tumors have revealed a number of changes that may yield clinically useful biomarkers following further development and validation studies. Diagnosis: The definitive MPM diagnosis relies on a tissue biopsy and demonstration of invasion. Diagnostic markers consist of a combination the expression of mesothelial-specific proteins and absence of markers of adenocarcinoma. Recent advances have shown that the mutation of the tumor suppressor BAP1 leads to loss of nuclear staining, and that this is highly specific for discriminating mesothelioma from benign conditions. As in some cases MPM has neither BAP1 mutation nor loss of nuclear staining, sensitivity is lacking, but this can be improved by incorporating detection of CDKN2A genomic loss using FISH. Assessment of additional mutations and fusion genes recently identified in MPM may represent useful markers for future development. Characteristic changes in microRNA expression are present in MPM, and these form the basis of a highly accurate molecular test for the differential diagnosis of MPM from other tumors affecting the pleura. Prognosis: Clinical and pathological parameters remain the best predictors of disease outcome, and although some molecular markers have demonstrated prognostic significance, these are yet to be validated. Histopathological subtype is an accurate prognostic indicator, with the epithelioid subtype associated with significantly better outcomes than the non-epithelioid biphasic and sarcomatoid types. The variation within epithelioid tumors is well recognized, and epithelioid tumors with a pleomorphic morphology have poor prognosis, similar to patients with non-epithelioid tumors. Recent results from transcriptomic analyses have revealed subsets within epithelioid and non-epithelioid tumors which more accurately describe prognosis. These include the two-cluster C1/C2 classification system based on a 3 gene predictor, and the 4 clusters (sarcomatoid,
Fig 1. Trends of tax income, tobacco consumption and smoking rate in Japan.6-8
Keywords: evidence-based policy, health effects, summary report
ED12.06 Tobacco Control Policies in Latin America Nise Yamaguchi,1 Norma Pilnik,2 Jaime De La Garza,3 Luis Ashton,4 Abel Garcia,5 Eduardo Bianco,6 Gregorio Kevorkof 7 1Clinical Oncology and Tumor Immunology, Hospital Albert Einstein, São Paulo/Brazil, 2 Internal Medicine Oncology Department, School of Medicine Cordoba University, Cordoba/Argentina, 3 Thoracic Oncology Unit and Laboratory of Personalized Medicine, National Cancer Institute, Mexico City/Mexico, 4 Auna, Lima/Peru, 5Cancer Prevention and Control, National Institute of Neoplastic Diseases, Lima/Peru, 6 Tobacco Epidemic Center, Montevideo/Uruguay, 7 Internal Medicine, National University of Cordoba, Cordoba/Argentina Introduction: Smoking is the single most important cancer risk factor and accounts for 26% of all cancer deaths and 84% of lung cancer deaths in Latin America.1 Lung cancer is one of the most preventable cancer types; and doctors of all expertise are essential to impart to patients and their families the idea of smoking prevention, thereby contributing to the reduction of mortality from lung cancer. There are around 145 million smokers age 15 years or older in Latin American. Adult smoking prevalence varies from 35% in Chile and 30% in Bolivia to 11% in Panama and 11. 7% in El Salvador.2,3 The continuing popularity of smoking among adolescents is particularly worrisome as smoking rates among teens and young adults predict future lung cancer rates.
Journal of Thoracic Oncology
Vol. 12 No. 1S
Smoking rates among young people aged 13e15 years are now higher than in adults in many Latin American countries. Prevalence among female adolescents has surpassed their male counterparts in Argentina, Brazil, Chile, Mexico, and Uruguay. Unless these high rates of smoking are curtailed, cancer mortality rates will continue to rise.3 We have assessed the impact on smoking rates of anti-tobacco policies adopted by five Latin American countries, in compliance to the WHO’s Framework Convention on Tobacco Control (FCTC). Argentina, Brazil, Mexico, Peru, and Uruguay were used as case studies to illustrate the challenges and ways in which governments and civil society organizations can effectively work together to reduce lung cancer deaths and other tobacco-related diseases. Since the endeavor for approving anti-tobacco policies was met with a strong lobby against it in these countries, different degrees of compliance with the FCTC terms were reached. We analyzed reports issued by local governments and epidemiologic surveys found in the literature. Tobacco farming in Latin-America has increased in recent years, representing almost 16% of the global production. Argentina and Brazil are among the ten largest world producers and the cultivated area in Latin America reaches 13.55% of the global land dedicated to tobacco farming worldwide. The prices paid by the tobacco industry to farmers are also increasing since 2007, and the sector employs 650,000 people. Tobacco farming is also present in Colombia, Dominican Republic, Honduras, Ecuador, Guatemala, Mexico, Nicaragua and Paraguay.4 Therefore, tobacco control policies must necessarily include solutions to help tobacco growers to escape from the influence of the tobacco industry without loss of income and jobs. Results: We have found a differential decrease (and increase) in smoking among the population of the studied countries in the last decades: Argentina: (from 29% in 2007 to 22.1% in 2014); Brazil (from 34.8% in 1989 to 14.7% in 2013); Mexico (21.7% in 2008-2011 to 23.6% in 2014); Peru (from 44.5% in 1998 to 21.1% in 2010 and 13.3% in 2013); Uruguay (from 34% in 1998 to 23.5% in 2011).5e11 Discussion: According to the 2014 FCTC Progress Report12, the implementation degree of the articles among the countries varied from <20% to more than >75% in most cases. One-third of all FCTC signing countries have not enacted anti-tobacco legislation or reached the full implementation of at least two important time-bound articles: tobacco advertising ban and health warnings on cigarette packages and at the selling points. Our data also showed uneven degrees of implementation among the studied countries. One of
January 2017
the underlying causes for slow implementation in some countries, like Mexico and Argentina, is the strong political lobby by the tobacco industry. In our study, Argentina has come in third in smoking prevalence, with a 22.1% smoking rate among adults, due to the strong pressure upon legislators by the tobacco industry that so far has prevented the FCTC ratification by the Congress. Nevertheless, the Argentinean political environment was more sensitive than the Mexican, to the persistent anti-smoking advocacy by the medical associations and organizations of the civil society. Therefore, some of the FCTC tobacco control policies were enacted by legislators in 2011 and implemented in 2013. Mexico, however, was the one with the poorest implementation of tobacco control policies and the highest in smoking prevalence among adults (23,60%), seconded by Uruguay (23.5%), where the past administration has neither enforced the already existing tobacco-control policies, nor promoted new ones, such as heavy taxes upon tobacco products. One of the important measures recommended by the FCTC — which has proved to be effective in smoking prevention among children and teenagers — is high taxation (over 75%) of tobacco products.12 Conclusion: The degree of compliance with the terms of the Convention seems to have a direct impact on the reduction of smoking rates in the countries studied. Other solutions should contemplate tobacco farmers, whose fear of shifting to new unfamiliar cultures is exploited by the tobacco industry to prevent FCTC ratification in many countries. But farmers should not stop growing tobacco plants, but just shift to transgenic tobacco farming13. Transgenic tobacco is being successfully tested for expression of for more than fifteen human therapeutic proteins, including antibodies, antigens for vaccines, and autoimmune inhibitor factors.(14-17) Pharmaceutical companies could benefit from the existing agricultural tradition of tobacco farming in Brazil, Argentina, and elsewhere by fostering the commercial production of those molecules. Transgenic tobacco is improper for smoking and could also have the nicotine gene knocked out to discourage misuse. Therefore, the pharma industry could open new roads to smoking eradication while preserving the economic activity and profitability of traditional tobacco farmers. Effective tobacco control requires a close cooperation between health institutions, medical societies, NGOs, and the press - and the regular funding of surveillance programs and educational campaigns. Smoking prevention programs must be part of the educational curricula from the pre-school onwards. Keywords: anti-smoking policies, smoking rates, biofarming, Tobacco Control
Abstracts
S57
ED13.02 Tissue-Based Biomarkers Glen Reid,1 Steven Kao,2 Nico Van Zandwijk1 Asbestos Diseases Research Institute, Sydney/Australia, 2 Medical Oncology, Chris O’Brien Lifehouse, Sydney/Australia
1
Introduction: Malignant pleural mesothelioma (MPM) is difficult to diagnose and accurate prediction of patient outcomes still relies on a range of clinical scores. Despite extensive efforts in the last decade, there are few tumorbased molecular markers that can accurately contribute to diagnosis and prediction of disease course. Recent reports describing the mutational and transcriptional landscape of MPM tumors have revealed a number of changes that may yield clinically useful biomarkers following further development and validation studies. Diagnosis: The definitive MPM diagnosis relies on a tissue biopsy and demonstration of invasion. Diagnostic markers consist of a combination the expression of mesothelial-specific proteins and absence of markers of adenocarcinoma. Recent advances have shown that the mutation of the tumor suppressor BAP1 leads to loss of nuclear staining, and that this is highly specific for discriminating mesothelioma from benign conditions. As in some cases MPM has neither BAP1 mutation nor loss of nuclear staining, sensitivity is lacking, but this can be improved by incorporating detection of CDKN2A genomic loss using FISH. Assessment of additional mutations and fusion genes recently identified in MPM may represent useful markers for future development. Characteristic changes in microRNA expression are present in MPM, and these form the basis of a highly accurate molecular test for the differential diagnosis of MPM from other tumors affecting the pleura. Prognosis: Clinical and pathological parameters remain the best predictors of disease outcome, and although some molecular markers have demonstrated prognostic significance, these are yet to be validated. Histopathological subtype is an accurate prognostic indicator, with the epithelioid subtype associated with significantly better outcomes than the non-epithelioid biphasic and sarcomatoid types. The variation within epithelioid tumors is well recognized, and epithelioid tumors with a pleomorphic morphology have poor prognosis, similar to patients with non-epithelioid tumors. Recent results from transcriptomic analyses have revealed subsets within epithelioid and non-epithelioid tumors which more accurately describe prognosis. These include the two-cluster C1/C2 classification system based on a 3 gene predictor, and the 4 clusters (sarcomatoid,