Helping Cancer Patients Quit Smoking Should Be a Standard of Care

Overwhelming evidence presented in the 2014 Surgeon General’s Report resulted in the conclusion that smoking causes adverse outcomes in patients with cancer.¹ Current smoking increases risk for overall mortality by a median of 51% and increases the risk of cancer-specific mortality by a median of 61%. Smoking further increases the risk of developing a second primary cancer and has strong associations with an increased risk of toxicity from cancer treatment. One or more adverse effects of smoking are noted across virtually all cancer disease sites and for all treatment modalities including surgery, radiotherapy, and systemic therapy.

Graham W. Warren, MD, PhD

Associate Professor

Vice Chairman for Research

Department of Radiation Oncology

Hollings Cancer Center Medical University of South Carolina Charleston, SC

Yet despite these data, most oncologists do not regularly provide evidence-based tobacco cessation support for patients with cancer who smoke.² Some of the reasons that oncologists do not offer this support include not feeling confident in their ability to assist their patients in stopping smoking, a lack of time, and a lack of available resources.³

However, addressing tobacco use by patients with cancer is not as difficult as some might think. Established evidence-based guidelines are available⁴ and online resources have been developed specifically for use by clinical oncologists.⁵ Recent reviews have discussed methods to improve cessation support for patients with cancer that basically rely upon asking patients about tobacco use, advising patients to quit smoking, and assisting patients in quitting smoking using principles of behavioral counseling and pharmacotherapy.^6,7 Physicians and other clinical providers can directly assist patients with cessation support or can refer patients to resources such as dedicated institutional tobacco cessation programs, state help line services, or specialized counselors who can be integrated into a busy oncology clinic.

Recognizing the merits of such efforts, leading cancer organizations such as the American Society of Clinical Oncology, the American Association for Cancer Research, and the International Association for the Study of Lung Cancer have advocated for providing cessation support to all patients with cancer who use tobacco.^8-10

Hollings’ Model Reaches All Smokers

Clinicians and researchers at the Hollings Cancer Center (HCC) at the Medical University of South Carolina (MUSC) have seized upon these recommendations to develop a dedicated cessation program to provide assistance to all patients with cancer who use tobacco. Prior work demonstrated that an automated referral process for patients to a dedicated cessation program was very well received by patients,¹¹ with more than 90% expressing an interest in participating in tobacco cessation.

K. Michael Cummings, PhD, MPH

Professor

Psychiatry and Behavioral Sciences Hollings Cancer Center Medical University of South Carolina Charleston, SC

Through this platform, patients are screened for tobacco use using a structured tobacco assessment; all patients identified as using tobacco within 30 days of assessment are referred for cessation support, and all patients are followed to ensure that they are using recommended evidence-based cessation treatments and making progress toward quitting. Patients can opt out of the tobacco cessation program, but the service is offered to all patients as a standard of care.

Patients are contacted by a trained cessation counselor who discusses the adverse effects of smoking on their cancer treatment and the need to quit smoking as an important part of their cancer care. Patients are then further assessed for how ready they are to quit using tobacco, what problems they have in quitting, what behaviors they can change, and what medications are needed to help them quit. An individualized tobacco cessation treatment plan is developed, and patients are followed to help ensure that they are able to maintain a successful quit attempt.

The program at HCC is coupled with an inpatient program available to all hospitalized patients at MUSC. All inpatients who report smoking at admission are automatically referred to a dedicated inpatient tobacco cessation counselor, who then rounds on patients to discuss the importance of quitting smoking. Evidence-based recommendations are placed into the electronic medical record for clinicians to reference for patient treatment. Upon discharge, patients are then followed with an automated interactive voice recorder system that tracks tobacco use and provides real-time referrals to South Carolina’s Tobacco Quitline for patients who request additional help.

Using this design, HCC and MUSC are able to effectively screen patients for tobacco use, deliver evidence-based cessation support as a standard of care, document interventions, and obtain follow-up data. Using an automated approach reduces selection bias for physician referrals and allows more patients who need cessation support to receive evidence-based care. In patients with a mandatory referral for cessation support at HCC and MUSC, more than 90% of cancer patients and more than 80% of inpatients are receptive to cessation support.

Moreover, this approach allows clinicians to focus on other aspects of medical care. Locating cessation services in the hallway across from clinic allows for clinics to continue operating at a high volume without being slowed for behavioral counseling sessions and medications. Clinicians can also facilitate cessation without a strong experience base by advising all patients to quit smoking and allowing evidence-based cessation to be provided by trained counselors.

Clear Imperative for Programs

With the conclusive evidence that smoking causes adverse outcomes in cancer patients,¹ the need to provide evidence-based tobacco cessation support is clear. Clinicians should evaluate effective methods to help their patients quit smoking as a standard part of cancer care and should realize that many patients are receptive to help. Clinicians who are reticent about providing cessation support themselves should engage institutions, insurers, and the community to develop dedicated tobacco cessation resources to help patients quit smoking. Collectively, tobacco cessation may be one of the most effective adjunctive agents to improve cancer treatment outcomes.

References

1. US Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014.Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2014.
2. Warren GW, Marshall JR, Cummings KM, et al. Practice patterns and perceptions of thoracic oncology providers on tobacco use and cessation in cancer patients. J Thorac Oncol. 2013;8(5):543-548.
3. Warren GW, Marshall JR, Cummings KM, et al. Addressing tobacco use in cancer patients: A survey of American Society of Clinical Oncology members [published online July 29, 2013]. J Oncol Pract. 2013;9(5):258-62.
4. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use And Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service; May 2008.
5. American Society of Clinical Oncology. Tobacco cessation and control resources. http://www.asco.org/practice-research/tobacco-cessation-and-control-resources. Accessed February 26, 2015. (last referenced 2-26-15)
6. Warren GW, Sobus S, Gritz ER. The biological and clinical effects of smoking by cancer patients and strategies to implement evidence-based tobacco cessation support [published online October 26, 2014]. Lancet Oncol. 2014;15(12):e568-580. 2014.
7. Karam-Hage M, Cinciripini PM, Gritz ER. Tobacco use and cessation for cancer survivors: an overview for clinicians [published online May 9, 2014]. CA Cancer J Clin. 2014;64(4):272-290.
8. Toll BA, Brandon T, Gritz ET, et al. Assessing and stopping cancer patients’ tobacco use: an American Association for Cancer Research policy statement [published online April 9, 2013]. Clin Cancer Res. 2013;19(8):1941-1948.
9. Hanna N, Mulshine J, Wollins DS, et al. Tobacco cessation and control a decade later: American Society Of Clinical Oncology policy statement update [published online July 29, 2013]. J Clin Oncol. 2013;31(25):3147-3157.
10. Cummings KM, Dresler CM, Field JK, et al. E-cigarettes and cancer patients. J Thorac Oncol. 2014;9(4):438-441.
11. Warren GW, Marshall JR, Cummings KM, et al. Automated tobacco assessment and cessation support for cancer patients [published online October 25, 2013]. Cancer. 2014;120(4):562-569.