While the images and influence of the Marlboro Man may fade into the background for those who remember this pervasive icon in glossy magazine ads, many people continue to use tobacco products, despite its proven association with many types of cancer.

Public education efforts and indoor smoking bans have helped to decrease cigarette smoking; however, the use of smokeless tobacco has increased.1 Unfortunately, some smokeless tobacco products are touted as the “smarter alternative” to traditional tobacco cigarettes, 2 but that doesn’t mean they are without risks.

Further research is needed to determine if products, such as electronic cigarettes, may lead to the development of lung cancer, but they can still cause damage to the lungs.3 (Related: Are e-Cigarettes Safe, or Just Safer?)

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Advice from the Health Care Team        

The challenge remains for medical professionals to speak to patients about tobacco use and to encourage cessation, especially after a cancer diagnosis.  To aid the discussion, the American Society of Clinical Oncology (ASCO) has recently updated its 2003 policy statement on tobacco cessation, reaffirming its commitment to helping patients understand the dangers of tobacco and the importance of quitting.1

Although it may be common knowledge that lung cancer is caused largely by smoking, it is important to convey to patients that other types of tobacco usage may lead to cancers of the mouth, lips, nasal cavity and sinuses, larynx, pharynx, esophagus, stomach, pancreas, kidney, bladder, uterus, cervix, colon/rectum, ovary, as well as acute myeloid leukemia.4

The risks of continuing to use tobacco products are numerous. These include higher risk of cancer recurrence, reduced treatment effectiveness, and shorter survival, among others. 1 However, quitting smoking and the use of tobacco products offers many benefits, such as improved cancer treatment outcomes, reduced adverse effects, decreased risk of infection, and improved breathing and quality of life, all of which lead to increased survival.

The policy statement also reminds practitioners that they should not use tobacco themselves in order to help patients by being a good example.

Ask the Question: Do You Use Tobacco?

Finding out if patients currently use, or formerly used, tobacco products on a regular basis is crucial. ASCO provides a Tobacco Cessation Guide that helps introduce the discussion to patients. 5 The guide—free to download online— can be used to help motivate patients to quit by giving them evidence-based strategies to stop using tobacco and shows how to incorporate tobacco-dependence treatment into practice. Treating nicotine-dependence for patients with cancer is not a one-size-fits-all approach, however, and the treatment may need to be tailored for each patient, just like other aspects of cancer care.

“Tell your patients that the most important thing they can do to help their treatment is to stop tobacco use,” says Graham Warren, MD, PhD, Radiation Oncologist at Roswell Park Cancer Institute, Buffalo, NY, in the guide.

Current Status of Tobacco-related Issues in Practice

To learn more about how oncologists are addressing the issue of tobacco use with patients, ASCO surveyed 1,197 of its current members. The results, published in the Journal of Oncology Practice, show that most (86%) agreed or strongly agreed that tobacco cessation should be a standard part of clinical care. Most (90%) reported that they ask patients if they use tobacco, and 82% said that they recommend patients quit.

Interestingly, fewer than half (44%) said that they discussed medication options either always or most of the time.6  This is where the Tobacco Cessation Guide can help—it lists evidence-based methods that have been successful. For example, U.S. Food and Drug Administration–approved therapies, such as nicotine replacement therapy, have helped patients quit for good (20%); when coupled with counseling, the quitting rate increases to 30%.5

Quitting tobacco can be a major obstacle for a patient, especially after a cancer diagnosis when stress levels are very high. With a patient-specific, multi-faceted quitting intervention that includes counseling and follow-up, there is hope for them to become tobacco-free for good. If patients need additional reminders that tobacco is dangerous, it might be helpful to remember that two actors who played the Marlboro Man in advertising campaigns— Wayne McLaren and David McLean—both, sadly, died of lung cancer.7


1. Hanna N, Mulshine J, Wollins DS, et al. Tobacco Cessation and control a decade Later: American Society of Clinical Oncology policy statement update.  J Clin Oncol. 2013 Jul 29. [Epub ahead of print] http://jco.ascopubs.org/content/early/2013/07/29/JCO.2013.48.8932.full.pdf+html

2. Rise from the ashes. http://www.youtube.com/watch?v=VZishwAt_RM (Accessed August 5, 2013)

3. Flouris AD, Chorti MS, Poulianiti KP, et al. Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function. Inhal Toxicol. 2013 Feb;25(2):91-101 http://www.ncbi.nlm.nih.gov/pubmed/23363041

4. Tobacco-Related Cancers Fact Sheet. Cancer Facts & Figures 2013. American Cancer Society. http://www.cancer.org/cancer/cancercauses/tobaccocancer/tobacco-related-cancer-fact-sheet Accessed August 5, 2013

5. Tobacco Cessation Guide for Oncology Professionals. http://www.asco.org/sites/default/files/tobacco_cessation_guide.pdf (Accessed August 5, 2013)

6. Warren GW, Marshall JR, Cummings KM, et al. Addressing tobacco use in patients with cancer: A survey of American Society of Clinical Oncology members. JOP. 2013 Jul 29. http://jop.ascopubs.org/content/early/2013/07/25/JOP.2013.001025.abstract

7. The Marlboro Man. NPR. Oct 21, 2002 http://www.npr.org/programs/morning/features/patc/marlboroman/ (Accessed August 5, 2013)