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Research & Evidence

Dual use of ENDS and other tobacco products is common and generates little to none of the positive health impacts of quitting combustible tobacco products altogether.
Key issues surrounding the health impacts of electronic nicotine delivery systems (ENDS) and other sources of nicotine
Drope, J., Cahn, Z., Kennedy, R., Liber, A. C., Stoklosa, M., Henson, R., Douglas, C. E. and Drope, J
CA: A Cancer Journal for Clinicians


"The Costs of Cancer." American Cancer Society Cancer Action Network,

This ACS CAN report focuses specifically on the costs of cancer for patients in active cancer treatment as well as survivors. It examines the factors contributing to the cost of cancer care, the types of direct costs patients face, and other costs and hardships associated with cancer. To more fully illustrate what people with cancer actually pay for care, the report presents profiles of several typical cancer patients and shows what they paid when they had different types of insurance coverage. 

The report presents public policy recommendations for making cancer treatments more affordable for patients, survivors and the health care system as a whole. The American Cancer Society Cancer Action Network (ACS CAN) is making cancer – and the affordability of cancer care – a top priority for public officials and candidates at the federal, state and local levels. 

Mariotto, Angela B.; Lindsey Enewold; Jingxuan Zhao; Christopher A. Zeruto; K. Robin Yabroff. "Medical Care Costs Associated with Cancer Survivorship in the United States." Cancer Epidemiology, Biomarkers & Prevention, June 10, 2020.

Background: The prevalence of cancer survivorship is increasing. In this study, we provide contemporary population–based estimates and projections of the overall and site-specific cancer-attributable medical care costs in the United States.

Hu,Tian, Seana L. Gall, Rachel Widome, Lydia A. Bazzano, Trudy L. Burns, Stephen R. Daniels, Terence Dwyer, Johanna Ikonen, Markus Juonala, Mika Kähönen, Ronald J. Prineas, Olli Raitakari, Alan R. Sinaiko, Julia Steinberger, Elaine M. Urbina, Alison Venn,. "Childhood/Adolescent Smoking and Adult Smoking and Cessation: The International Childhood Cardiovascular Cohort (i3C) Consortium." Journal of the American Heart Association, April 8, 2020.

Despite declining US adolescent smoking prevalence from 40% among 12th graders in 1995 to around 10% in 2018, adolescent smoking is still a significant problem. Using the International Childhood Cardiovascular Cohort (i3C) Consortium, which includes 7 international cohorts recruited in childhood and followed into adulthood, the present study was designed to confirm the important relation between adolescent smoking and daily adult smoking and present new data on adult smoking into the forties and comparison of smoking in the United States, Finland, and Australia.

"Annual Report to the Nation: Cancer death rates continue to decline." National Cancer Institute, March 12, 2020.

The Annual Report to the Nation on the Status of Cancer finds that cancer death rates continued to decline from 2001 to 2017 in the United States for all cancer sites combined.

Canfell, DPhil, Karen; Prof. Jane J. Kim PhD; Prof Marc Brisson, PhD; Adam Keane, PhD; Kate T. Simmons, PhD; Michael Caruana, DPhil. "Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries." The Lancet, January 30, 2020.

WHO is developing a global strategy towards eliminating cervical cancer as a public health problem, which proposes an elimination threshold of four cases per 100 000 women and includes 2030 triple-intervention coverage targets for scale-up of human papillomavirus (HPV) vaccination to 90%, twice-lifetime cervical screening to 70%, and treatment of pre-invasive lesions and invasive cancer to 90%. We assessed the impact of achieving the 90–70–90 triple-intervention targets on cervical cancer mortality and deaths averted over the next century. We also assessed the potential for the elimination initiative to support target 3.4 of the UN Sustainable Development Goals (SDGs)—a one-third reduction in premature mortality from non-communicable diseases by 2030.

"Cancer Facts & Figures 2020." American Cancer Society, 2020.

Cancer Facts & Figures 2020 is an educational companion for Cancer Statistics 2020, a scientific paper published in the American Cancer Society journal, CA: A Cancer Journal for Clinicians. The Facts & Figures annual report provides:

  • Estimated numbers of new cancer cases and deaths in 2020 (In 2020, there will be an estimated 1.8 million new cancer cases diagnosed and 606,520 cancer deaths in the United States.)
  • Current cancer incidence, mortality, and survival statistics
  • Information on cancer symptoms, risk factors, early detection, and treatmen


Campbell, Kristin; Kerri M. Winters-Stone; Joachim Wiskemann; Anne M. May; Anna L. Schwartz; Kerry S. Courneya; David S. Zucker; Charles E. Matthews; Jennifer A. Ligibel; Lynn H. Gerber; Stephen G. Morris; Alpa V. Patel; Trisha F. Hue; Frank M. Perna; Kat. "Exercise Guidelines for Cancer Survivors." Medicine & Science in Sports & Exercise, November 2019.

In the last decade, the United States has seen a 27% decline in cancer deaths due to early detection and improved treatments for cancer. In turn, the number of cancer survivors is growing, with over 15.5 million cancer survivors in the United States—a figure that is expected to double by 2040 (1). Improved prognosis has created a growing need to address the unique health issues facing cancer survivors that result from the disease, its treatment, and related comorbid conditions. For example, the symptom of fatigue can persist in 25% of cancer survivors many years after their treatment has ended and contributes to difficulty returning to work, independent living, and poor quality of life (2). Furthermore, risk of developing heart disease may be elevated by some cancer treatments, and cardiovascular mortality is emerging as a major competing cause of death in cancer survivors along with cancer recurrence (3,4). Cancer is also a disease strongly linked with aging, and almost half of survivors are older than 70 yr (5). The adverse synergistic effects of age, cancer treatment, and related sequelae increase the total burden of cancer. Historically, clinicians advised cancer patients to rest and to avoid physical activity, but early exercise research in the 1990s and 2000s challenged this advice.

Patel, Alpa V.; Christine M. Friedenreich; Steven C. Moore; Sandra C. Hayes; Julie K. Silver; Kristin L. Campbell; Kerri Winters-Stone; Lynn H. Gerber; Stephanie M. George; Janet E. Fulton; Crystal Denlinger; Stephen G. Morris; Trisha Hue. "American College of Sports medicine roundtable report on physical activity, sedentary behavior, and cancer prevention and control." Medicine & Science in Sports & Exercise, November 2019.

It was estimated that 18.1 million individuals were diagnosed with cancer in 2018 and 9.6 million individuals died from the disease—making cancer the second leading cause of mortality worldwide (1). In the United States (US) alone, the lifetime risk of developing cancer is 40% in men and 38% in women (2), and 1.74 million individuals were diagnosed with cancer in 2018 (3). There are also high direct and indirect costs related to the cancer burden; for example, in the US alone, the annual cost of cancer care is US $158 billion (4), with billions of additional dollars lost to disability, lost work, and lost household productivity (5). Thus, the burden of cancer remains a significant public health issue worldwide, and there is an increasing need to understand how modifiable health behaviors like physical activity may help prevent and control cancer in the population.

Schmitz PhD, MPH, Kathryn; Anna M. Campbell PhD; Martijn M. Stuiver PT, PhD; Bernardine M. Pinto PhD; Anna L. Schwartz PhD; G. Stephen Morris PT, PhD; Jennifer A. Ligibel MD; Andrea Cheville MD; Daniel A. Galvão PhD; Catherine M. Alfano PhD. "Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer." CA: A Cancer Journal for Clinicians, October 16, 2019.

Multiple US and international organizations have published exercise recommendations for patients living with and beyond cancer, including the American Cancer Society (ACS),1 the American College of Sports Medicine (ACSM),2 Exercise and Sports Science Australia,3 Cancer Care Ontario,4 and the Clinical Oncology Society of Australia.5 In March 2018, the ACSM convened a Second Roundtable on Exercise and Cancer Prevention and Control. This second Roundtable included 17 organizations from multiple disciplines (see Supporting Table 1) and set out to review and update prior recommendations on cancer prevention and control. The products of this Roundtable include 3 articles.

Andy S L Tan; Soneji Samir, Moran, Meghan Bridgid; Choi, Kevin. "JUUL Labs' sponsorship and the scientific integrity of vaping research." The Lancet, August 3, 2019.

As of 2018, 98 countries regulate e-cigarettes, including their sale, marketing, packaging, manufacturing, taxation, reporting, and clean air laws.1 Some countries have banned e-cigarettes completely, such as Argentina, Saudi Arabia, and Singapore,1 whereas other countries, such as the UK, consider e-cigarettes as part of a public health harm reduction strategy.2 The USA has regulated e-cigarettes as a tobacco product since 2016. 

Walton, MS, Kimp; Teresa W. Wang, PhD; Gillian L. Schauer, PhD; Sean Hu, MD; Henraya F. McGruder, PhD; Ahmed Jamal, MBBS; Stephen Babb, MPH. "State-Specific Prevalence of Quit Attempts Among Adult Cigarette Smokers - United States, 2011-2017." Centers for Disease Control and Prevention - Morbidity and Mortality Weekly Report, July 19, 2019.

From 1965 to 2017, the prevalence of cigarette smoking among U.S. adults aged ≥18 years decreased from 42.4% to 14.0%, in part because of increases in smoking cessation (1,2). Increasing smoking cessation can reduce smoking-related disease, death, and health care expenditures (3). Increases in cessation are driven in large part by increases in quit attempts (4). Healthy People 2020 objective 4.1 calls for increasing the proportion of U.S. adult cigarette smokers who made a past-year quit attempt to ≥80% (5). To assess state-specific trends in the prevalence of past-year quit attempts among adult cigarette smokers, CDC analyzed data from the 2011–2017 Behavioral Risk Factor Surveillance System (BRFSS) surveys for all 50 states, the District of Columbia (DC), Guam, and Puerto Rico. During 2011–2017, quit attempt prevalence increased in four states (Kansas, Louisiana, Virginia, and West Virginia), declined in two states (New York and Tennessee), and did not significantly change in the remaining 44 states, DC, and two territories. In 2017, the prevalence of past-year quit attempts ranged from 58.6% in Wisconsin to 72.3% in Guam, with a median of 65.4%. In 2017, older smokers were less likely than younger smokers to make a quit attempt in most states. Implementation of comprehensive state tobacco control programs and evidence-based tobacco control interventions, including barrier-free access to cessation treatments, can increase the number of smokers who make quit attempts and succeed in quitting (2,3).

Blake, Kelly D., Amanda L. Klein, Laura Walpert, Len Casey, Cynthia Hallett, Clifford Douglas, Bidisha Sinha, Howard K. Koh. "Smoke-free and tobacco-free colleges and universities in the United States." BMJ Journals, July 2, 2019.


Objective To describe the number and proportion of accredited, degree-granting institutions with 100% smoke-free and 100% tobacco-free protections across the USA and by state.

Methods Data on postsecondary education institutions from the US Department of Education National Center for Education Statistics Integrated Postsecondary Education Data System 2015, and smoke-free and tobacco-free campus protections from the American Nonsmokers’ Rights Foundation’s Smokefree and Tobacco-Free Colleges and Universities List 2017, were integrated to calculate the number and proportion of: (1) smoke-free and tobacco-free accredited, degree-granting institutions and (2) students and staff protected by campus policies and state laws. Campus protections are given a 100% smoke-free designation if smoking is not allowed on campus anywhere, at any time; 100% tobacco-free designations extend smoke-free protections to include non-combustible products such as smokeless tobacco.

Results 823 accredited, degree-granting institutions (16.7%) representing 1816 individual campuses, sites and schools have either 100% smoke-free or 100% tobacco-free protections. An estimated 14.9 million college students (26.9%) and 8.9 million faculty and staff (25.4%) are protected by campus policies and state laws. Only three states and two territories have 100% smoke-free or 100% tobacco-free protections in over half of their institutions; four states and six territories have no known 100% smoke-free or 100% tobacco-free campus protections.

Conclusions In 2017, just 16.7% of accredited, degree-granting institutions in the USA had 100% smoke-free or 100% tobacco-free protections. Despite progress, more efforts can ensure that students and staff benefit from comprehensive 100% smoke-free and 100% tobacco-free protections at US colleges and universities.

Advances in cancer diagnosis and treatment have resulted in declining cancer mortality rates during the past 20 years [1], resulting in high rates of return to work following a cancer diagnosis [2]. Cancer survivors report that work provides a sense of normalcy, necessary financial support, and in some cases, social support [3]. Cancer survivors who work after diagnosis have unique needs to ensure optimal outcomes for both the individual and the employer. A supportive work environment is an important factor for success [4]. Work-related factors significantly associated with a greater likelihood of employment or return to work after cancer diagnosis include perceived employer accommodation, flexible work arrange-ments, and supportive services such as counseling, training, and rehabilitation [4].

Sauer, Ann Goding; Rebecca L. Siegel; Ahmedin Jemal; and Stacey A. Fedewa. "Current Prevalence of Major Cancer Risk Factors and Screening Test Use in the United States: Disparities by Education and Race/Ethnicity." American Association for Cancer Research, April 2019.

Overall cancer death rates in the United States have declined since 1990. The decline could be accelerated by eliminating socioeconomic and racial disparities in major risk factors and screening utilization. We provide an updated review of the prevalence of modifiable cancer risk factors, screening, and vaccination for U.S. adults, focusing on differences by educational attainment and race/ethnicity. Individuals with lower educational attainment have higher prevalence of modifiable cancer risk factors and lower prevalence of screening versus their more educated counterparts. Smoking prevalence is 6-fold higher among males without a high school (HS) education than female college graduates. Nearly half of women without a college degree are obese versus about one third of college graduates. Over 50% of black and Hispanic women are obese compared with 38% of whites and 15% of Asians. Breast, cervical, and colorectal cancer screening utilization is 20% to 30% lower among those with <HS education compared with college graduates. Screening for breast, cervical, and colorectal cancers is also lower among Hispanics, Asians, and American Indians/Alaska Natives relative to whites and blacks. Enhanced, multilevel efforts are needed to further reduce the prevalence of modifiable risk factors and improve screening and vaccination, particularly among those with lower socioeconomic status and racial/ethnic minorities.

Warren, MD, PhD, Graham W.; Kathleen B. Cartmell, PhD; Elizabeth Garrett-Mayer, PhD. "Attributable Failure of First-line Cancer Treatment and Incremental Costs Associated With Smoking by Patients With Cancer." JAMA, April 5, 2019.

The cost of cancer treatment is increasingly associated with unfavorable financial outcomes in cancer care,but whether increased costs reflect increased value is unknown. Principles for value-based care in oncology include patient-centered solutions, optimal care, and cost-containment strategies that do not limit patient access or innovation. Guidelines have been developed to define clinically meaningful outcomes in cancer care, but a recent analysis of drug approvals by the US Food and Drug Administration between 2014 and 2016 showed that many drugs did not meet survival goals.  Whereas drug cost and efficacy have been the primary focus for considering value in cancer care, relatively little consideration has been given to other potentially modifiable factors that could affect cancer treatment costs, including health behaviors such as smoking.

The US 2014 Surgeon General’s report concluded that continued smoking among patients with cancer caused adverse outcomes including increased overall- and cancer-specific mortality, risk for second primary cancer, and associations with increased toxic effects from cancer treatment. Smoking cessation in the general population is known to improve health outcomes and create significant reductions in health expenditures. Whereas many studies found that smoking cessation after a cancer diagnosis can improve survival, to our knowledge, there have been no evaluations of the association between continued smoking among patients with cancer and the costs of cancer treatment. Understanding the financial effects of smoking among patients with cancer is needed to develop value-based approaches that could lead to improved cancer treatment outcomes. The objective of this study was to model the additional attributable first-line cancer treatment failures associated with continued smoking and to estimate the attributable incremental cost associated with the need to treat first-line cancer treatment failures attributed to continued smoking.