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By NANCY FRAZIER O'BRIEN

The U.S. Surgeon General's 2014 report, "The Health Consequences of Smoking," describes the epidemic of smoking-related diseases over the past 100 years as one of the nation's "greatest public health catastrophes" and bemoans the fact that 19 percent of adult Americans still smoke tobacco.

The report notes progress in reducing smoking and smoking-related deaths in the 50 years since a Surgeon General's report first linked smoking to cancer, but warns that "very large disparities in tobacco use remain across groups defined by race, ethnicity, educational level and socioeconomic status and across regions of the country."

One of the states facing the greatest challenge is Kentucky, which leads the nation in both lung cancer incidence and lung cancer deaths. With 29 percent of its population smoking, Kentucky has more adult smokers than any state but West Virginia; it also is first in the nation in smoking prevalence among both middle-school and high-school students. Drawing on data from 2011, the Campaign for Tobacco-Free Kids, a national nonprofit organization, said 24.1 percent of the Kentucky's high school students smoked compared to a national rate of 18.1 percent.

Breaking habits
KentuckyOne Health, the state's largest health system, is confronting smoking and its health effects from a variety of angles — with personalized smoking cessation programs in several Northern Kentucky communities, lobbying efforts before the Kentucky Legislature and advanced diagnostic tools that improve the chances of identifying earlier stage cancers that may be more responsive to treatment.

"You might find it hard to believe — and I did at first too — but some people still don't really believe that smoking is linked to lung cancer," said Amanda Dumbacher, an oncology patient navigator and smoking cessation instructor for the Louisville-based KentuckyOne Health. The health system, part of Englewood, Colo.-based Catholic Health Initiatives, formed in early 2012 with the merger of Jewish Hospital & St. Mary's HealthCare of Louisville and Saint Joseph Health System of Lexington, Ky.

"Kentucky is a huge tobacco state," and many Kentuckians grew up "in a culture of seeing everyone around you smoking," she said. "And they tend to start smoking earlier, so there is such a strong tobacco addiction that the chances are it will stay throughout their lives."

KentuckyOne Health uses the Cooper/Clayton smoking cessation method for its free 13-week classes. The program, which has a high rate of success even for heavy smokers, combines education on smoking and its effects with training in use of nicotine-replacement patches and tips for stress management, social skills, weight management, nutrition and exercise.

"We say, 'Here are the things you may experience, and here are the tools to cope with them,'" Dumbacher said. "It is important that they know they are not going through this journey alone."

Protecting workplaces, schools
As KentuckyOne works to battle tobacco use one smoker at a time, the health system also is joining statewide efforts to ban smoking for all indoor workplaces and public places, including restaurants, bars and hotels. Louisville already has such a ban, but only about a third of all Kentuckians live in an area where a similar ban is in effect, according to the Smoke-Free Kentucky coalition. Sherri Craig, KentuckyOne's vice president of advocacy and public policy, said the public place smoking ban is a legislative priority for the health system.

State Sen. Julie Denton, R-Louisville, and Rep. Susan Westrom, D-Lexington, recently reintroduced legislation prohibiting smoking in workplaces and public places, an effort that they began in 2011. According to Smoke-Free Kentucky's website, a recent poll found that by a margin of 59 percent to 39 percent, Kentucky voters support a law that would prohibit smoking in most public places including workplaces, bars and restaurants.

Craig expressed support for the bill on behalf of KentuckyOne, along with Ken Marshall, president of University of Louisville Hospital, and Dr. Donald Miller, director of the James Graham Brown Cancer Center. That cancer center is part of the University of Louisville Hospital, which is part of KentuckyOne.

"Smoke-free policies are an easy way to solve a serious public health problem," Westrom said in a news release.

But for now, unless a school board expressly prohibits it, in most Kentucky municipalities, adults, including visitors, contractors, teachers and personnel, can smoke in designated spots on school property and in stadiums during sporting events. (Federal law prohibits smoking inside school buildings, and students can't smoke on school property.) However, a Tobacco-Free Schools initiative is gaining some ground in Kentucky, and to date, 32 school districts have passed a tobacco-free school policy, according to Betsy Janes, a spokesperson for the Smoke-Free Kentucky initiative. Studies show that smoking among students declines by 40 percent in schools that have been smoke-free for three or more years.

Deadly disease
The Surgeon General's 2014 report says more than 20 million Americans — including nearly 2.5 million nonsmokers exposed to secondhand smoke — have died as a result of smoking since that first report in 1964.

"More than 10 times as many U.S. citizens have died prematurely from cigarette smoking than have died in all the wars fought by the United States during its history," the 2014 report says.

Cancer screening
Lung cancer is one of the more difficult cancers to diagnose in early stages, when the disease can be more responsive to treatment. KentuckyOne Health now offers high-risk patients low-dose CT scans that provide physicians with a series of very detailed pictures of the lungs. The CT scans have been found to be four times more likely to pick up a mass than a traditional chest X-ray and early detection and intervention can reduce the risk of dying by 20 percent.

"Chest X-rays have never been found to reduce death by lung cancer, because they find it when it is at a more advanced stage," said Dr. Goetz H. Kloecker, director of the Thoracic Oncology Clinic at the James Graham Brown Cancer Center.

But a recently completed study by the National Institutes of Health followed 50,000 patients at high risk of contracting lung cancer for 10 years, with half of them receiving chest X-rays and half CT scans. The study confirmed the beneficial effects of the low-dose CT scan in preventing lung cancer deaths, Kloecker said, and Medicare has been directed to make the screening a paid benefit for certain patients by the end of the year. "Then private insurers will follow," he added.

When KentuckyOne first began offering the more advanced CT screening a year and a half ago, Kloecker said, the very first patient who was screened was found to have early-stage lung cancer and is now continuing to receive treatment.

The low-dose CT scan "catches cancer before the patient shows symptoms," he said.

The more advanced screenings are not for everyone, however.

"It would do more harm than good in terms of incurring worries and costs to screen everyone," Kloecker said. The high-risk patients who can benefit the most from the low-dose CT scans, the NIH determined, are those between the ages of 55 and 79 who have smoked at least 30 pack years. A pack year is defined as one year of smoking one pack of cigarettes a day.

"Early detection gives you more options for treatment, including taking advantage of clinical trials, but the best prevention for lung cancer is to stop smoking or never start," Kloecker said.

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Tobacco's grip on Kentucky

• Economic cost due to smoking $3.76 billion
• Adult smoking rate 28.3 percent
• High school smoking rate 24.1 percent
• Middle school smoking rate 9.0 percent
• Smoking-attributable deaths 7,848

Source: "State of Tobacco Control 2014," American Lung Association