Lung Cancer Lecture Notes PDF

Lecture 1: Overview of Lung Cancer Cancer Occurs when: the nature process of apoptosis has been damaged When genetic material of a cell DNA is damaged- mutations arise potentially disrupting normal growth and division. Accumulations of mutations can turn normal cells into precancerous cells, which s...

Lecture 1: Overview of Lung Cancer Cancer Occurs when: the nature process of apoptosis has been damaged When genetic material of a cell DNA is damaged- mutations arise potentially disrupting normal growth and division. Accumulations of mutations can turn normal cells into precancerous cells, which sometimes multiple and evolve into cancer cells. Cancer is the result of the accumulation of cells Cancer develops when the body’s normal control mechanism stops works- cells grow out of control- tumor Cancer cells differ: - Grow in the absence of cells telling them to grow - Ignore signals that normally tell cells to stop dividing or die - Invade into hereby areas and spread to other areas of the body - Tell blood vessels to grow toward tumors Cancer by numbers: - More than 200 diff types of cancers - Cancer is the second leading cause of death - CDC reports that in 2020 every 100,000 there are 403 new cancer cases were reported - 144 died of cancer causes of Causes of Cancer: - Environmental: Radiation, Chemical Carcinogen exposure, exposure to sun UV - Behavior: alcohol, tobacco, certain foods, excessive exposure to sun UV - Genetic- some cancers have genetic origin Most Common Cancers About 50% of cancers - Breast cancer - Lung Cancer - Prostate cancer - Colon and rectum cancer Disaggregating cancer incidence and mortality: - The incidence and prevalence of cancer differs across numerous dimensions including age, sex, race and ethnicity and place - As we age there is more time for damage in our cells to build up - Further as we age we have more exposure to the behavioral and environmental factors that cause cancer Cancer mortality by sex, race, and ethnicity - Cancer mortality rate is higher for men than women - Differs by race- highest in African Americans and lowest in Asian/pacific islanders - Cancer mortality by sex, race and ethnicity is a consequence of difference s and disparities in behavioral factors - Prostate, lung, and colorectal cancers account for an estimated 43% of all cancers in men. - In women→ lung, breast and colorectal account for 50% of cancers in women Geography of Cancer LUNG CANCER 🚬🫁 It is one of the most common forms of cancer in the US It is preventable Its is increasingly a public health success story In the United States in 2020: - 197,453 new lung cancers were reported - 136,084 people died from lung cancer  - Males had higher rates of getting and dying from lung cancer *Age adjusted rates of lung cancer have been falling on average 2% each year over 2010-2019. Age adjusted death rates have been falling on average 4.1% each year over 2011-2020. The Doll-Hill Study - Lung cancer might be cause by all sor - Lung cancer might be correlated with location or educational attainment: smoking and lung cancer are correlated, low education and lung cancer are correlated, location and correlation The relationship between smoking and lung cancer is not instantaneous→ how to prove the relationship? - Observational ongoing prospective cohort study design - Doctors in Britain were used as their prospective cohort- because it eliminates confounding variable - Which differentiated the doctors which was whether they consumed tobacco products and if so in what quantity Lecture 2: Study Designs Overview → Clinical Research: independent variable → dependent variable Epidemiological Research: Exposure → Outcome Observational Studies Cross sectional: exposure and outcome at the same time - You cannot claim causation but association or correlation - Can graph exposure and outcome to find relationship Cohort prospective: exposure → outcome *time matters - Looking for exposure and how many experience incidence (have it) - Looking for non exposure incidence Case control retrospective: outcome → exposure - Studying the cases of who has the disease - Who is exposed and who is not exposed - Matched demographically Ecologic - Seven Countries Study by Ancel Keys 🍷 - The French are eating more cholesterol but the deaths are low- so crazy!! - Wine is good for you Experimental Studies: **Observe what occurs in response to investigator induced change in exposure Randomized Clinical Trials  - Double Blind Placebo Controlled- gold standard- decrease bias! Community Trials - Community = intervention unit, not individual Overall Questions to Ask - Research question- last paragraph of introduction - Hypothesis Testing - Appropriate Conclusion (supported by data) Clinical Trials - THEY BETTA BE DESCRIBING THEIR RANDOMIZATION TECHNIQUES! - No bias - Blinding? Who was blinded, who was not? Cohort Studies (Observational) - Study representative- of the research question population - All variables accounted for - confounding - Adequate length of time - time to get to an outcome Cross Sectional (Observational) - Sample Clearly Defined- who is the subject and demographic? Where did you recruit from- educational level? - Representative- level of severity Tables and Figures - Are the tables and figures stand alone? - Can you interpret the data without the supporting text? - Does the data truly support the text with information? - Practical or Clinical Significance (vs Statistical Significance) - Physiological perspective - ask yourself it is really that important? Approaches to Reading a Paper: Topic of Interest - Abstract, INtro, DIscussion - General knowledge, leads to other papers in content area Approach - Methods - Procedural, duplication, innovative approach Outcomes - Methods, Results (tables and figures), Discussion - Relational rigor, contribution to field Learning - All Sections Summary - Study design is critical to what a study can and cannot answer: relational vs causal - Critically reading studies is important: don't take the authors word for it - Reading research papers is a sk8ll that develops over time: practice takes time Biological Aspects of Lung Cancer Learning Objectives 1. To introduce lung cancer as a serious and life threatening medical conditions 2. To define cancer and its biological hallmarks 3. To consider the translational implications of cancer cell biology Lung Cancer has poor prognosis: - Lung Cancer is the leading cause of cancer mortality worldwide- 1.8 million individuals died in 2020 - It is often detected at progressed stages when symptoms are more predominant Lung Cancer: - Can be prevented through decreasing risk factors 4/10 cancer cases can be prevented Types of Lung Cancer 1. Small cell lung cancer (SCLC) - Less common type of lung cancer - Occurs almost exclusively in heavy smokers - Poorer prognosis 2. Non-small cell lung cancer (NSCLC) - Encompasses several types that behave in a similar way: squamous cell carcinoma, adenocarcinoma, large cell carcinoma What is cancer: abnormal cells grow uncontrollably Malignant and tumors and metastasis - Lung cancer begins with lung structures- bronchi, bronchioles, alveoli, outer parts of lungs- and may spread to other parts of the body (metastasis) The Cell Cycle  - An intrinsic property of a cell is to be able to divide and pass the genetic information to its daughter cell- the cell cycle is a series of steps that take place for the cell to faithfully replicate its genetic material and divide Interphase: - G1 Phase: the cell grows, and copies organelles and other cell contents in preparation for DNA synthesis - S Phase- the cell makes a complete copy of their DNA - G2 Phase: cell grows more, makes proteins, and prepares for mitosis Mitosis and cytokinesis - The cell nucleus and cytoplasm divide to yield to identical cells G0 - Resting state that cells can stay here for a long time Checkpoints: - Transitions through cell phases are regulated at by different checkpoints - They direct and repair eros *Cancer is the failure at these checkpoints and propagation of errors - mutations Genes serve as instruction manuals: - A gene is the basic physical and functional until of heredity - Composed of cody and non coding regions of DNA- used to make proteins (transcription factors, growth factors, hormones, cytokines, chemokines) - Proteins have many biological roles: cell growth, cell survival, cell motility Oncogenes vs Tumor Suppressor Genes Two classes of genes accosted with cancer; 1. Oncogenes: mutated versions of normal genes that promote cell proliferation, motility and survival 2. Tumor suppressor genes (TSGs): normal genes that inhibit cell proliferation motility and survival- including programmed cell death Cancer Results from mutations in key genes: - a faithful copy of the DNA leads to activated to cause cancer via three distinct pathways 1. gene mutation- point mutation- alteration of gene sequence to yield mutant protein. 2. gene amplification: normal sequence is repeated in the chromosome to yield excess protein 3. gene translocation- movement of a genetics whence from its normal chromosomal position to a new production to heirs novel fusion protein - move to different region Cancer Cell Development 1. Damage to DNA: gene mutation, gene amplification, gene translocation 2. Transmission of DNA error 3. Latency 4. Progression *Cancer progression depends on the accumulation of cancer hallmarks Six Classical Hallmarks of Cancer Growth factor Independence - Synthesis and release of the growth factors asre tightly regulated to maintain normal cell growth function- ligands can be cytokines and hormones - Cancer cells achieve self sufficiency in growth factors by 3 mechanisms 1. Make growth factor to stimulate their own and neighboring receptor 2. Alter the number, structure or function growth factors receptors on their cell surface so that they are more likely to relay a growth signal 3. Deregulate downstream signaling pathways- constitutive activation Insensitivity to anti growth signals - In normal cells anti growth signals counteract the positively acting growth signals to promote cells into the G0 stage of the cell cycle. - Anti growth signals regulate cell cycle progression via specific regulatory proteins coded by tumor suppressor genes - Cancer cells inhibit anti growth signaling pathways: reduced receptor number and sensitivity to anti growth signals, enable mutations to tumor suppressor genes. Activating Invasion and Metastasis - Normal cells maintain usual boundaries and reside in specific locations *Metastasis is the spread of cancerous cells from an initial or primary site to a different or secondary site - Invasion and metastasis involves 6 steps Detachment: of tumor cell from its local site and neighboring cells Enzymatic digestion of surrounding tissue Migration to and penetration of blood or lymphatic vessels Survival in the circulation until arrival at a favorable secondary site Attachment the blood vessel wall at the secondary site and extravasation from vessel  Proliferation and invasion of its new location and recruitment of a new blood supply - Cancer cells are able to alter the epithelial to mesenchymal (blood, tissue, lymphatic cells) transition: aka the ability to transition from a differentiated cell type to a dynamic cell type with varied capabilities Enabling Replicative Immortality - Normal cells undergo a fixed number of cell divisions before they enter a state of permanent growth arrest: replicative senescence - Senescence occurs because cells cannot fully replicate the ends of their chromosomes at each division- telomeres get progressively shorter with time, act as molecular clocks that count down cells lifespan Inducing Angiogenesis *Angiogenesis is the process of new blood vessels forming from existing blood vessels in the body. - Growth of new blood vessels is controlled by a balance between pro angiogenic (positive) and anti-angiogenic (negative) signals - Cancer’s ability to progress depends on its ability to secure a blood supply - Cancer cells have an “angiogenic phenotype Promotes production of pro angiogenic proteins Promotes decreased production of anti angiogenic proteins - Fosters a microenvironment that favors creation and maintenance of blood supply Resisting Cell Death - Normally cells continually assess their viability through cell cycle checkpoints and undergo Apoptosis if damage exceeds repair. - In cancer there is a loss of normal cell death pathway signaling - Cancer cells evade apoptosis by: Extrinsic Pathway: ability to ignore death signals sent through the immune system. Intrinsic pathway: reset the balance of intracellular pro and anti survival molecules within the mitochondria - Cancer cells are able to sustain DNA damage without causing cell death Newer Hallmarks of Cancer  1. Reprogrammed Energy Metabolism - Cancer cells switch their metabolism to preferential use of glycolysis with generation of lactate- The Warburg Effect - While appearing wasteful in terms of energy reproduction, shift provides important substrates for cancer cell growth and division 2. Evasion of Immune Destruction - Cancer cells are immunogenic and actively recruit immunosuppressive cells to their vicinity to evade immune surveillance - Enables growth and spread of tumors without becoming a target for immune clearance Therapeutic Targeting of Cancer Hallmarks Take Home Messages: 1. Lung Cancer is one of the most common cancers worldwide and presents as either small cell lung cancer or non small cell lung cancer. 2. Prognosis for lung cancer is poor, claiming more lives per year than colon, prostate, ovarian and breast cancer combined. 3. Cancer is a large group of diseases caused by mutations to genes that control normal cell proliferation, survival and motility. 4. Cancer cells display 8 hallmarks that account for their malignant properties. 5. Understanding cancer cell biology has led to the development of drug therapies that specifically target these cancer hallmarks. Biological Aspects of Lung Cancer 2 Lecture Goals: Contrast Major Types of Lung Cancer Types of Lung Cancer: *Lung cancer is typically divided into two major types based on the appearance of the cancer cells 1. Small Cell Lung Cancer: least common, occurs almost exclusively in heavy smokers , only 7% of patients survive 5 years post diagnosis 2. Non small cell lung cancer: encompasses several types that behave in a similar way Anatomy: of Lung Cancer Main Types of Cancer: classified by cell type origin  1. Carcinoma: originates from epithelial cells: skin or tissues that line organs - 80-90% of all cancer including lung cancer Lung Cancer- Disease of the Respiratory System - Respiratory system is a group of organs and structures that enable breathing and gas exchange of O2 and CO2 - Bilateral asymmetric structures that occupy the thoracic cavity lay atop the diaphragm - House conduits for air and serve as a site of gas exchange Functional Anatomy: 1. Conduction Zone: conduits to gas exchange sites: trachea, bronchi 2. Respiratory Zone: site of gas exchange, includes microscopic structures- alveoli **Structures are hollow → lined with epithelial cell subtypes- serve as interface tissue Large airways and alveoli cell types are varied Origins of SCLC and NSCLC Diagnosis is determined by analyzing the certain cell type origin SCLC: - Represents 15% of all lung cancers: neuroendocrine carcinoma - Poor prognosis: exceptionally high proliferation rate- strong tendency for early metastasis - Late stage diagnosis is common–> ⅔ of patients present with metastasis - Earlier stage diagnosis is amenable to curative therapy Risk Factors of SCLC - SCLC comprises 250,000 cases per year - Greatest risk factor is cigarette smoking - Aligns with mutational profiling of SCLC tumors - Exceptionally high rate of mortality compared to solid tumor cancer Cell Biology in SCLC Inactivation if two tumor suppressor genes are integral to SCLC pathogenesis: 1. TP53 gene: codes for tumor protein P53 2. RB1 gene: Codes for retinoblastoma protein Both RB and p53 play key roles in regulating cell cycle progression  - RB is an inhibitor of s phase entry - P53 is integral to multiple cell cycle checkpoints **In cancer these genes are mutated and malfunctioning. Disease Presentation Patients present with respiratory symptoms - Cough - Dyspnea- labored breathing - Hemoptysis- coughing up blood Radiological findings are generally unequivocal - Lung mass - Thoracic lymph node - DIstant metastatic lesions: ⅔ of patients will have Disease Staging - Involves tumor biopsies: primary lesions and local lymph nodes - Tumor node metastasis classification system reflects disease progression- distinguishes limited stage from extensive stage disease: grades from T1-T4 - TNM classification is beneficial in defining optimal treatment strategies Stages of Lung Cancer Stage 1: Limited Stage -restricted to one side, primary lesion is less or greater than 3cm Stage 2: Limited Stage- also restricted to one side, but primary lesion is greater than 5-7 cm without lymph node involvement, or evidence of spread to adjacent tissue Stage 3: Locally advanced disease- cancer has spread beyond lyph nodes on both sides of the chest and there is involvement medically situated lymph nodes Stage 4: Extensive stage disease- cancer is accompanied by pleural effusion or distant metastasis, build up of fluid in lungs, distant lesions in brain, bone, or liver When diagnosing a type of lung cancer: T stands for Tumor N stands for Nodes M stands for metaphysis Management of SCLC: Early Stage Disease: Surgery or radiotherapy Locally Advanced Disease: chemoradiotherapy Extensive Metastatic Disease: ChemoIO and immunotherapy *Patients within SCLC are high risk of relapse within 2 years - 75% of patients with locally advanced disease - 90% of patients with metastatic disease Take Home Messages 1. Lung Cancer is one of the most common cancers worldwide and presents as either SCLC or NSCLC. 2. NSCLC and SCLCare derived from neuroendocrine cells lining the respiratory tract- why it is a carcinoma. 3. Lung cancer staging reflects location and size of the primary tumor degree of lymph node involvement and evidence of metastasis.  4. Treatment of SLC is tailored to disease stage and involves combination chemo and radiotherapy for locally advanced disease and introduction of immunotherapy with extensive metastatic disease. 5. Recurrence of SCLC is high and newer, more effective therapies are needed. Discussion: Small Cell Lung Cancer Definition: Study Rationale: Research Question: What is the effectiveness Study Population: Study Design: Primary Outcome: Results: Main Findings: Subgroup Analysis: Social Determinants of Health (1) Outline: - Health Equity - Social Determinants of Health - Application: Boulder Health Equity Committee “Take Two Steps Forward Video”: - Not everyone starts in the same playing field - Not everyone can see what we bring to the “field” and backgrounds - Given the same size Inequality: tree is bending to one side Equality: same size ladder but the tree is leaning to one side Equity: given a taller ladder - Who we are, where we live and how much money we make. - Opportunities for health are equal but not defined by identity Justice: fixing the system (fixing the ladder) Health Disparities: A particular type of health difference that is closely linked with social economical and environmental disadvantages Need to understand disparities to determine equity Social Determinants of Health: conditions in which people are orn, grow, live, work and age Zip Code Matters: neighborhoods and built in environment - Housing - Transportation - Parks - Playgrounds - Walkability - zip code/ geography Social and Community; A sense of belonging Economic stability: workforce opportunity in communities - Employment - Income - Expenses - Debt - Medical bills - support Education and access: to quality education- early childhood education - Literacy - Language - Early childhood education - Vocational training - Higher education - Community colleges Childhood experiences: where they grow up, violence, trauma, acute experiences→ social support and education Food security and access - Social integration - Support systems - Community engagement - Stress - Exposure to violence/ trauma - policing / justice policy Health Care system - Health coverage - Provider and pharmacy availability - Access to linguistically and culturally appropriate and respectful care - Quality of care **Politics heavily influence these decisions Health Factors: Understanding the context of a person and their experiences 40% Socioeconomic Factors - Education - Job Status - Family Support - Income 10% Physical Environment - Housing 30% Health Behaviors - Tobacco Use - Diet and Exercise - Alcohol use - Sexual Activity 20% Health Care - Access and Quality of Care World Health Organization: Social Determinants of Health - Poverty related to food insecurity - Structural conflict: refugees and political unrest How to address these disparities? 1. Improve daily living conditions - Equity from the start - Healthy places healthy people - Fair employment and decent work - Social protection across the life course - Universal Health Care 2. Tackle the inequitable distributions of money, power and resources: includes - Health equity in all policies, systems and programs  - Fair financing - pharmaceuticals - Market responsibility - Gender equity - Good global government - Political empowerment - inclusion and voice- what role should they play? 3. Measure and understand the problem and assess the impact of action How do we promote health equity? 1. Awareness: Hearts and Minds → values, emotions, purpose 2. Capacity Building: Behaviors→ norms, practices, skills 3. Action: Structures → processes, strategies, structures Equity ecosystem: - Diversity equity and inclusion → requires a diversity of entities individuals and families - Community Leadership → relationships and intentional collaboration across sectors - Systems Transformation → ask and look across systems and policies Example: Boulder Health Equity Fund - Trying to understand and Application of Health Equity Lens - Demographic Data - Disease rates - Self Efficacy - Service Access - Community Partnerships - Physical Activity - Food Security and Nutrition Theory of Change Model Inputs → Activities → Outputs → Short Term Outcomes → Intermediate Outcomes → Long Term Outcomes Advancing Health Equity: - Preventing and Treatment Health Service - Education, Engagement and Advocacy - Interventions on SDOH - Strategic Partnership Development - Health Equity, Education and Training Framework for Health Equity and Well Being **Spend time on the ISMS and Geography in the rural urban divide Diversity vs Inclusion - What - How - Who is in the room - Having a voice in the room - Focuses on demographics - The state of being valued respected and - Brings different people into the same supported territory - Focuses on allowing differences to coexist in a mutually beneficial way - Introduces concrete methods and strategies to make diversity work Health Equity and Lung Cancer Questions about Social Determinants of Health: Equality, Equity, Equality, Equity Why DO U.S. Cancer Health Disparities Exist? 1. Environmental Factors - Air and water quality - Transportation - Housing - Community safety - Access to healthy food sources and spaces for physical activity 2. Social Factors - Education - Income  - Employment - Health Literacy 3. Behavioral Factors - Tobacco use - Diet - Excess body weight - Physical Inactivity - Adherence to cancer screening and vaccination recommendations 4. Cultural Factors - Cultural beliefs - Cultural health beliefs 5. Psychological Factors - Stress - Mental Health 6. Biological and Genetic Factors Casual Pathways of Lung Caner: Exposure → Outcome Smoking Lung Cancer Occupational toxins **Goal is to find the Confounder (variable) between exposure and outcome: race/ethnicity, SES, Gender Exposure: Amount smoking topography, methanol, cessation Outcome: Diagnosis and screening, treatment and survival Article: Cancer health disparities in racial/ethnic minorities in the US - Healthcare: insurance: private and medicaid - Socioeconomic status Other modifiable and non modifiable - Environmental pollution - Birthplace Country of Origin - Genetics- epigenetics - Molecular Biology of tumors Lung Cancer Disparities Incidence: AA/B men have he highest incidence rate → more than double other race/ethnicities Hispanics and Asian women → have the lowest incidence (½ other ethnicities) Exposure-Smoking: Lung cancer rates differ by 2-3 fold by race when exposed to the same carcinogen Contributions  - Screening and Treatment: Lower rates of scans by R/E for screening and standard of care - Genetics and Tumor Biology: greater than 50% of Lung Cancer diagnoses are in never smokers Article: Integrating Multiple Social Statuses in Health Disparities Research: The Case of Lung Cancer Intersectionality- examines how multiple factors combine to facilitate or restrict exposures and outcomes Between Gender Race and SES Lung Cancer Outcomes: Key Points: - Lung Cancer is not just biological - Social processes, institutions and response to health care are key contributors - More research with diverse groups - Transdisciplinary approach is warranted The exposures: RAPED GOATS R-radiation A-aging P-pollution E-environmental D-disease G-genetics O-occupation A-asbestos T-tobacco S-smoke Article: Racial Disparities in occupational risks and lung cancer incidence: Analysis of the national Lung Screening Trial RCT! Key Findings: - AA had a higher rates of Lung CA diagnosis compared to whites - AA reported more occupational exposures than whites Research Design: Exposure: Occupational Toxins Confounding Factors: Age, gender, Family History of Lung Cancer, BMI, smoking status, pack years of smoking Outcome: Lung Cancer Results: Summary: - Application of Health Equity to Lung Cancer - Intersectionality - health is very multi dimensional - Key Takeaways from reading research articles Economic Aspects of Tobacco Use and Lung Cancer Overview: - Addressing the problem of lung cancer and tobacco use through public policy interventions - Assessing the effectiveness of different types of intervention - Challenges of attributing causality *Smoking is more prevalent with those who did not complete higher education or high school *Smoking is more prevalent among individuals with lower incomes Applying an Economic Lens: The Case for Public Action Why regulates or tax tobacco: Externalities associated with tobacco use and lung cancer  - Second Hand Smoke: exposure to tobacco smoke is hazardous to health of non smokers - Fiscal costs Smokers impose higher costs of publicly provided of health care Smokers are more likely to die early, and thus put less demands on social security and Medicare in later life Assessing the relative magnitudes of these is difficult Why regulate or tax tobacco: 1. Smoking prunes connections in the adolescent brain 2. The last part of the brain to develop and mature is the prefrontal cortex- the decision making part of the brain 3. As the prefrontal cortex develops, adolescents rely of the amygdala to make decisions and solve problems- associated with impulses and emotions 4. SO in adolescence one is more open to acting on impulse rather than considering the longer term consequences So in the case of smoking - Adolescents can take up smoking which provides an immediate reward and the harms are not processed or ignored - Smoking and nicotine is addictive - In the long term smokers regret taking up smoking: and regret not thinking about their future self. - This implies that individuals might be better off if we raised the current cost of tobacco consumption or reduced the current benefits Applying an Economic Lens: Forms and Effectiveness of Public Actions Consider the Following: Provision of information, Taxes, Place-based bans Public Action: Provision of Information - There are thousands of anti-smoking campaigns and messages, but it depends who is consuming this information and if their peers and family are influenced by this information - These ideals are consistent with the fact that smoking has declined faster among ind with higher levels of education and more slowly among certain racial and ethnic groups Public Action: Taxes - Cigarettes are heavily taxed, As of January 2024, the average state plus federal excise tax on a pack of cig was under 3.00 which represents almost 40% of the tax inclusive retail price - Taxes per pack range from a low 0.17 in Missouri to a high of 5.35 in NY state - In certain cities such as NYC smokers are taxed an additional 1.50 per pack Are Taxes effective? - Cross Border Shopping to purchase cheaper cig - Substitution effects if cigarettes become more expensive, do consumers switch to other products? Like Alcohol, Marijuana, Vapes Public Action: Evidence on Taxes  - Taxes are unlikely to explain why smoking fell prior to 2000 because before US cig taxes were modest - Data shows there was a larger reduction in smoking by teenagers with the taxes → As teenagers are more price sensitive Public Action: “Place Based” Smoking Bans - In US consumers are increasingly limited in where they can smoke - Thirty five states ban smoking in restaurants and bars and 30 ban smoking in workplaces - Logic of the bans: make it hard to smoke by increasing the monetary cost of smoking and address the concerns associated with second hand smoke. Assessing their effects: - DO such bans reduce smoking or just displace it? - Some evidence suggests that smoking bans in restaurants and bars increase exposure smoke in children surveyed on weekdays - Workplace smoking bans increase children’s exposure to cig smoke on weekdays Summary: - Reductions inc ig use has been a public health success story in the US - Rates of Lung Cancer are declining but… there is the increase in e-cigarettes, marijuana, populations who smoke may be harder to reach - We want to be sure that the benefits of such actions outweigh their disadvantages Discussion 2: Tobacco Discussion 1) Discussion: Social and economic aspects of tobacco use