introduce our first speaker, Professor Matthew Steliger from the United States, who is a long-term colleague. He's the past chair of the ISLC Tobacco Control Committee, and he is, I think, one of the very few thoracic surgeons globally who is also a certified tobacco treatment specialist. So welcome, Matthew. All right, well thank you. And thank you to the ISLC and the World Conference. It's an honor to be here. I was asked to speak about the effect of smoking on survival and is it too late to quit. And I'll just get to the punchline. No, it's not too late. You can see the bus. The bus is leaving. He thinks he's late, but the door is still open. He can still hop on. So it's never too late to quit. But I'm gonna go through some of the data that shows why it's not too late to quit. Okay, so a quick overview. What's our mission? What's our ISLC position statement? And I'll give some examples of certain cohorts or populations where there is a benefit to cessation in multiple different ways. And just a picture for attention. Even Vincent van Gogh, over 140 years ago, knew that there was a link between tobacco and health. So why are we here? I won't read the entire mission. We can find it. It's on the web page. It's right there. But key point is in the third paragraph there, to use all available means to eliminate lung cancer and other thoracic malignancies. We're here to make people's lives longer and better using all the tools we can. The IASLC has a position statement on tobacco. Our committee worked very hard on this and we're very grateful for the support of the organization. And note, this is not my position statement. This is not a committee position. This is the organization's position statement. And again, I'm not going to read all the fine print, but in that first bullet point, all cancer patients should be screened for tobacco use and advised on the harm. All. Not the ones we think might quit, the ones we think might benefit. That guy, yes. No. All patients who smoke can benefit. And where did this come from? Well, there is NCC on guidelines. There is a United States Surgeon General's report. And I'll dig a little bit into the data on the U.S. Surgeon General's report because it has excellent overview of the data and very in-depth analysis. I can't get into all the weeds there, but they reviewed 10 studies, seven prospective cohort studies and three retrospective studies, nearly 11,000 cancer patients. And this was the question. Is there benefit for cessation after a cancer diagnosis? Now, this isn't lung cancer. Specifically, it's cancer. But they found overwhelmingly that, yes, there was benefit. Some of the studies I'll pick out and talk about the high points here. But this was one of surgical patients, surgical patients with lung cancer. And in their prospective cohort, they found impacts on overall survival. The significant impacts were three areas. Age, nodal disease. Yes, because of staging and prognosis and persistent smoking. And look at the effect of persistent smoking. It has an effect on survival like nodal disease. It's greatly linked to survival. And I'm not going to read off all the relative risks there. But you can see that those who've recently quit do demonstrate benefit of relative risk there that is significantly better than those who continue smoking even after diagnosis. All right. Small cell lung cancer. This was a single center study from the Mayo Clinic. And this was also in the Surgeon General's report. At the single center study, they retrospectively looked at patients who quit at or after their diagnosis, and they cut the risk of death by 45%. That's incredible. If we had a drug that did this, if we had a therapy that did this, but this is those who quit versus those who don't. And yes, there's other confounding factors of perhaps socioeconomic demographic factors, support, other things like that. But this is a difference of those who quit versus those who don't. And it does impact survival. Another paper. This is non small cell lung cancer, but this was published in J.T.O., our journal. This is IASLC's publication right here. And look at that survival curve. That is not a drug. That's not a surgery. It's not a radiotherapy regimen. That is tobacco versus no tobacco. There's a split in those curves. It's very significant. 20 versus 29 months. Now, this is all comers with lung cancer, and they were all who had been smoking at enrollment and those who quit versus those that didn't. There's a nine month survival difference. And it's not just nine months, but it's nine months of quality. It's nine months of better life. And it's significant there. If we had drugs that did that, it would newly become the standard of care. We'd be talking about it. Those pharmaceutical industries, their stock price would bounce up. Everybody would get excited about a survival curve like this. But look at that. That is something that's controllable. It's a risk factor, and it can be done. I'm not sure if there's radiotherapists in the audience here, but it affects patients undergoing radiation therapy. These are patients undergoing stereotactic radiation therapy for early stage lung cancer, getting a fairly what I would think is a curative intent treatment, 50 to 54 grade, three to five fractions. And they had 87 who continued to smoke afterwards with 32 quit. And the cessation after SBRT was associated with improved two year overall survival to your overall survival impact with cessation versus not. And there's likely oncologic and non oncologic factors there because we know that cessation improves other categories of disease. So this is a very large cohort of patients from the United States. V. A. Hospitals. If anybody here has worked in the U. S. V. A. Hospitals, um, yeah, their records are very detailed. The CPR system. You can mind quite a lot of data out of that. And so the this is a group from ST Louis, and they looked through overall survival at the U. S. Veterans Hospitals in a 10 year time period of nearly 7500 patients and found significantly shorter overall survival for those who continued to smoke. What's interesting with this, if you dig in a little bit more, is disease free survival did not change. So cancers could come back or not. Um, that was not impacted by their smoking status, but their life expectancy was. And so that makes me think there may be non oncologically driven factors that impact survival. Okay. In the J. T. O. Just this past year, there was a meta analysis, and this was an incredible amount of work. Look at that again. If that was a therapy, I mean, I'm not a statistician, but the evidence is very clear in this group of lung cancer patients overall. And then in these where it's studies that only focused on non small cell or small cell, the meta analysis demonstrated significant improved survival in patients who were not smoking after diagnosis. And so the evidence is there. No, it's not too late. Yes, you can quit. Um, and even after curative intent therapy like surgery is done, cancer is out. All done. There's another study. This is about quality of life. Those who continued smoking, they did not return to their baseline physical strength or their function in 12 months post operatively or even social functioning. And interestingly, they had worse pain, worse symptoms and worse breathing in those who continue to smoke. So it does matter and impact quality of life as well as survival. So in summary, yes, there are benefits in all patients in early disease patients. We can benefit them before therapy after therapy with quality of life. Of course, it impacts second primary and other disease categories. Afterwards, regional disease. You know, I heard Dr Donington talk about the return to intended oncologic therapy in the plenary session yesterday. Do they go through with the plan? People who have inter or multidisciplinary cancer care to get what they're supposed to. And I think that tobacco can impact this, whether they have respiratory illnesses or other other disease progression. Um, of course, metastatic disease. There's improved survival with cessation and supportive care with their symptoms. It can benefit all patients at any time. And I'll close with one little anecdote. I had a patient, not a lung cancer patient. She was an esophageal cancer patient, and we had found on exploration he had metastatic disease. He was not curable. Okay. And he came back to clinic to see me, and, uh, he he'd he'd been doing well, and he was getting treated with chemotherapy, and he quit smoking. So you're able to quit. And he said, Yeah, yeah, I quit. I'm like, Oh, great. Great. Are you feeling better? He goes, I'm not giving another dollar to that business. I'm like, What do you mean? He said, Cigarettes have taken away my life. They've taken away my health, and every damn day they've taken away my money. I am not going to give them another dollar. And so it was one controllable thing he could have on his life. And we hear about financial toxicity and the financial toxicity of a few dollars of a pack of cigarettes is small compared to the cost of cancer care. But in that patient's eyes, every pack of cigarettes was making him poorer and subsidizing industry that contributed to his illness. And that was I had not thought of it in that way. And so I think that in him, his cessation, it benefited him by giving him some sense of control, some sense of perspective and some sense of change in his life where he wasn't going to continue to subsidize an industry that contributed to his illness. So thank you.

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