Thursday, May 12, 2005

New Lung Cancer Alliance Ad Campaign Trying to Dissociate Lung Cancer from Smoking

Rivka Weiser of the American Council on Science and Health has exposed a new advertising campaign by the Lung Cancer Alliance -- a national nonprofit organization dedicated to advocating for people living with or at risk for lung cancer -- to try to increase funding for lung cancer research by emphasizing that most patients who are diagnosed with lung cancer are not smokers. The advertisement, featured in Tuesday's New York Times, has a picture of a lung cancer victim with the text: "This lung cancer patient can't stop smoking. Because she never started."

The main ad text states: "There’s no question that millions of lung cancer patients have died because of smoking. But it’s also true that over 50 percent of the people now being diagnosed with lung cancer are non-smokers or former smokers. In spite of this, the stigma of smoking
is still so great that lung cancer is underfunded, under-researched, and generally ignored by Congress." It concludes: "It’s time to treat lung cancer research with the same urgency that we bring to every other major cancer. Because the most lethal cancer in the country can no longer be hidden behind a smoke screen."

The Rest of the Story

While the goal of this ad campaign is laudable and more federal funding should be placed into lung cancer research, including its prevention, detection, treatment, and cure, I agree with Weiser that the advertisement may be misleading to the public. The ad headline refers to an individual whose lung cancer is unrelated to active smoking. But the subsequent text lumps together nonsmokers and ex-smokers in order to be able to attribute the appearance (i.e., diagnosis) of lung cancer to people who do not smoke. Thus, the reader is, I think, led to believe that the majority of lung cancer cases are unrelated to smoking. This is quite misleading, as 85% of lung cancers are attributable to smoking.

Presumably, the premise of the ad is that lung cancer is underfunded because smoking has a stigma attached to it and since most lung cancer is associated in the public eye with smoking, the disease as a whole is viewed as basically a disease of smoking and therefore the smoking-related stigma is hurting lung cancer research funding. So to avoid this problem, the ad aims to dissociate lung cancer somewhat from smoking. It aims to portray lung cancer as something other than a smoking-related disease. It aims to avoid the smoking-related stigma and thus increase funding for lung cancer.

Unfortunately, I believe both the means and the ends of this approach are flawed. The means are problematic because however important lung cancer research may be, it does not seem appropriate to use an approach based on misleading people to achieve that end.

The ends themselves, however, are flawed in two ways. First, by working to dissociate the public perception of an integral link between smoking and lung cancer, the ad is undermining decades of efforts of public health professionals and organizations to establish a clear association between smoking and lung cancer in the public's mind (which is essential, since lung cancer is an epidemic caused by smoking and a clear public perception of the overwhelming link between smoking and lung cancer is essential for efforts to prevent and reduce smoking). Thus, the overall message is inconsistent with public health efforts to tie lung cancer and smoking inextricably in the public's mind. At worst, the ad is reminiscent of tobacco industry efforts in the past to undermine the link between smoking and lung cancer. Although this was obviously not the goal, the fact that the ad may have this unintended consequence suggests that the approach taken in the campaign is not appropriate.

Second, by implying that funding for lung cancer research is justified specifically because most people affected do not currently smoke, the ad actually increases, rather than decreases the stigma associated with smoking and reinforces, rather than dubunks the view that funding of research for diseases should be based on the overall impact of the disease and not on how society views the behaviors or other factors associated with the disease.

So instead of saying, "Hey - smokers are human beings who have equal right to research and treatment for their diseases regardless of whether smoking is viewed as being socially acceptable," the ad is basically taking as a premise the fact that smokers are somehow lower-class citizens and their diseases are not equally deserving of research and treatment, but "Hey - most people who are diagnosed with lung cancer don't smoke at the time of diagnosis, so can't we just ignore the fact that they probably smoked in the past?"

There is no reason why society should devote less research funding to smoking-related diseases because they are caused by an unpopular behavior, nor is there any reason not to devote research funding to AIDS due to the stigma associated with the behavioral risk factors for that disease, nor should we reduce research funding for any disease because of any stigma attached to its underlying risk factors. It's time to end the stigma - period. Or at least to force policy makers to ignore societal stigma in making their funding decisions.

Feeding into these destructive stigmas may have short-term funding appeal, but I do not think it is the best long-term solution.


Anonymous said...

Lung cancer research and treatment and visibility has suffered from the "blame the customer" framing that has made tobacco industry profits so rich and comfortable.

That's what we mean by "stigma" here. Blame the customer.

Unfortunately, this ad campaign feeds into the stigma, validates it, exactly because it tries to sidestep it.

What would have been better: expose that most lung cancer is a direct and completely predictable result of massive and highly effective promotion of the number one cause of lung cancer by an industry that's never hesitated to put its profits above its customer's lives: the tobacco industry. Expose that virtually all lung cancer victims got addicted as children to a product designed for that event to happen.

Bill Godshall said...

My first impression of this ad in the NY Times was very different; that the woman in the picture got lung cancer from being exposed to tobacco smoke pollution.

I also thought the two underlying messages in the ad were that exsmokers and nonsmokers will continue getting lung cancer in the future due to their past smoking and their past exposure to smoke, and that Congress and others should fund efforts to detect lung cancer earlier in its more treatable stage (e.g. CT scans).

Bill Godshall

Fred Grannis MD said...

May 10, 2005

Misleading Advertisement about Lung Cancer

By Rivka Weiser

The statement

"However, it is extremely misleading to lump

the two groups together by saying that "over 50

percent" of lung cancer cases are diagnosed in

non-smokers and former smokers."

is completely wrong.

In my practice, more than 50% of lung cancer is seen in patients who ARE either never-smokers or ex-smokers. Further subdividing this group would yield a statement something like this.

"Most (approx. 80%) of these patients are ex-smokers, but there is a substantial number of my patients who are never-smoking women. Many have no exposure to involuntary smoking that I can detect on taking a careful history."

Some important background information:

The ad shows a picture of Karen Parles, a colleague and friend who has advanced lung cancer and who has never been a smoker, nor has she ever been exposed to substantial exposure to involuntary smoking.

Her case raises an important problem in lung cancer patients; i.e. adenocarcinoma of the lung in women who have never smoked. Although small cell lung cancer never (in my 30+ yr. experience) occurs in never smokers, and although squamous cancer very rarely occurs in never-smokers, and although all non-small cell lung cancer is uncommon in never-smoker men, about 25% of NSCLC, usually bronchioloalveolar CA and adeno CA occur in women who have never smoked. Karen's case is an unfortunate example of this problem. The global problem is that these women are left behind by all current prevention and early detection research activity. Smoking cessation will not help. Clean air legislation will potentially prevent the cases caused by involuntary smoking (est. 3000 cases/yr.), but will not help patients like Karen. Early detection activity will not include them, because they are not in a high-risk group, i.e. smokers or ex-smokers.

Although "only" 25% of women with lung cancer fall into this category, this makes up a cohort of almost 20,000 women each year! This is an enormous public health problem that you trivialize in your article. Recent information suggests that perhaps more of these women that we have previously realized have LC caused by involuntary smoking. This problem then becomes an opportunity to push smoke-free environments.

The second part of the message in this ad is the very important fact that ex-smokers remain at risk of lung cancer, with their continuing risk dependent upon their past smoking exposure and age. A classic example of why this is so important to emphasize is the new web page put out by some boneheads at the American Cancer Society

"Great American Health Check" on line.

that they say will help people assess their cancer risk. Although this web page asks whether individuals are current smokers, they do NOT ask whether they are EX-SMOKERS and do not inform them that they may be at HIGH risk of cancer based upon this past activity.

Before people address unfair criticism toward the good people of the Alliance for Lung Cancer Advocacy, Support and Education, they should think about these important considerations and consider apologies where appropriate.

Here are web pages that provide more information on the people who are involved in this advertisment.

ALCASE, (the Alliance for Lung Cancer Advocacy Support and Education),

and Lung Cancer Online Research Foundation

The second is an advocacy organization started by Karen Parles.

By way of disclosure, I am on the Scientific Advisory board of LCORF.

Fred Grannis MD

Long Beach CA