cancer prevention in primary care: a collective role? · patterns and trends in adult obesity...
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Cancer Prevention in Primary Care: a collective role?
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
• E-cigarettes
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
• In 2017-18, budgets for SSS were cut in 50% of local authorities. This follows cuts in 59% of LAs in 2016/17 and 39% in 2015/16
• A specialist stop smoking service open to all smokers is now provided by only 61% of LAs in England.
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.
Patterns and trends in adult obesity
Overweight and obesity among adultsHealth Survey for England 2013 to 2015 (three-year average)
Adult (aged 16+) overweight and obesity: BMI ≥ 25kg/m2
Almost 7 out of 10 men are overweight or obese (66.8%)
Almost 6 out of 10 women are overweight or obese (57.8%)
Trend in severe obesity among adultsHealth Survey for England 1993 to 2015 (three-year average)
Patterns and trends in adult obesity
Adult (aged 16+) severe obesity: BMI ≥ 40kg/m2
Prevalence of excess weight among childrenNational Child Measurement Programme 2017 /18
Patterns and trends in child obesity
Child overweight (including obesity)/ excess weight: BMI ≥ 85th centile of the UK90 growth reference
More than 1 in 5 children in Reception is overweight or obese
(boys 22.9%, girls 21.8%, all children 22.4%)
More than 1 in 3 children in Year 6 is overweight or obese
(boys 36.4%, girls 32.2%, all children 34.3%)
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 is 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) that individuals who know the links between alcohol and cancer and obesity and cancer are…
• More supportive of effective population level policies
Primary responsibility for tackling alcohol related harms is seen to rest with individuals, thealcohol industry, and the national government
More than 4 in 5 people want to know about the health harms associated with alcohol
• 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 this 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
Very Brief Advice for smoking cessation
• Can be delivered in fewer than 30 seconds
Establish and record smoking status
Advise on how to stop smoking
Offer help by directing to support & treatment
Very Brief Advice for smoking cessation
Advice on e-cigarettes is low (27%)
Prescribing pharmacotherapy is low• 22% prescribe NRT• 16% prescribe varenicline• 4% prescribe buproprion
53% of primary care
practitioners frequently
complete VBA
Very Brief Advice for smoking cessation
Very Brief Advice for smoking cessation• Easily accessible training in VBA and GPs can employ this
tool to help patients to stop smoking.
• Good to be aware of treatment options available to patients in your local area (NI in a better place than others in the UK on this…)
• Where clinically appropriate, prescribe pharmacotherapy and support the use of e-cigarettes as an aid to stop smoking.
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.
E-cigarettes
Prevalence of e-cigarette use
Use of e-cigarettes has remained stable since late 2013
0
5
10
15
20
25
2013-4 2014-1 2014-2 2014-3 2014-4 2015-1 2015-2 2015-3 2015-4 2016-1 2016-2 2016-3 2016-4 2017-1 2017-2 2017-3 2017-4 2018-1 2018-2 2018-3
Perc
ent
Use in smokers and recent ex-smokers
N=30262 adults who smoke or who stopped in the past year
0
5
10
15
20
25
30
35
40
45
50
20
11
-2
20
11
-3
20
11
-4
20
12
-1
20
12
-2
20
12
-3
20
12
-4
20
13
-1
20
13
-2
20
13
-3
20
13
-4
20
14
-1
20
14
-2
20
14
-3
20
14
-4
20
15
-1
20
15
-2
20
15
-3
20
15
-4
20
16
-1
20
16
-2
20
16
-3
20
16
-4
20
17
-1
20
17
-2
20
17
-3
20
17
-4
20
18
-1
20
18
-2
20
18
-3
Perc
ent
of
smo
kers
an
d r
ecen
t ex
-sm
oke
rs
Any
Daily
Prevalence of nicotine use: never & long-term ex-smokers
E-cigarette use among long-term ex-smokers has grown but use by never smokers remains negligible
N=80180 never and long-term ex-smokers from Nov 2013
0
5
10
15
2013-4 2014-1 2014-2 2014-3 2014-4 2015-1 2015-2 2015-3 2015-4 2016-1 2016-2 2016-3 2016-4 2017-1 2017-2 2017-3 2017-4 2018-1 2018-2 2018-3
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
Young people’s use of EC in Great Britain 2018, age 11-18 by smoking status
Source: McNeill, A, Brose, L, Calder, R, Bauld, L, Robson, D (2019) Vaping in England: An evidence update, Public Health England. Notes: (Unweighted bases: Never smokers = 1,739, former smokers = 359, current smokers = 162). Percentages have been rounded to the nearest whole number.
0
10
20
30
40
50
60
70
80
90
100
Never used an EC/not aware of EC Tried an EC once or twice Use sometimes, but less than oncea week
Use at least weekly Used an EC in the past but nolonger
%
Never smoker Former smoker Current smoker
What about safety?
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
But then…. (same Newspaper: The Sun)…different headline
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
• Intake similar to combustible cigarettes > 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
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
0
5
10
15
20
25
30
35
40
45
50
20
09
-3
20
09
-4
20
10
-1
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-2
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-3
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10
-4
20
11
-1
20
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-2
20
11
-3
20
11
-4
20
12
-1
20
12
-2
20
12
-3
20
12
-4
20
13
-1
20
13
-2
20
13
-3
20
13
-4
20
14
-1
20
14
-2
20
14
-3
20
14
-4
20
15
-1
20
15
-2
20
15
-3
20
15
-4
20
16
-1
20
16
-2
20
16
-3
20
16
-4
20
17
-1
20
17
-2
Perc
ent
of
smo
kers
try
ing
to s
top
E-cigs
NRT OTC
NRT Rx
Champix
Beh'l supp
Source: West, R, Brown, J, Beard, E (2017) www.smokinginengland.infoN=12859 adults who smoke and tried to stop or who stopped in the past year; method is coded as any (not exclusive) use
The TEC Trial: Very 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
At the population level…most vapers have stopped smoking
Source: McNeill, A, Brose, L, Calder, R, Bauld, L, Robson, D (2018) Evidence
review of e-cigarettes and heated tobacco products. A report commissioned by Public Health
England. London: Public Health England.
https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-
products-evidence-review/evidence-review-of-e-cigarettes-and-heated-tobacco-
products-2018-executive-summary
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 40% of smokers in Great Britain have never tried vaping
•
•
•
•
•
•
•
What your patients read in the papers…
The result: harm perceptions
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
More or equally harmful Less harmful Completely harmless Don't know
Compared with cigarettes, e-cigarettes are.....
2013 2014 2015 2016 2017 2018
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 and cancer matters online learning
