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Health workers vital to tobacco-control efforts for smokers with cancer

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Why would someone with cancer keep smoking?

In order to answer this “simple” question, one must first understand what tobacco use represents.

Tobacco use is responsible for 438,000 deaths in the United States each year, making it the leading preventable cause of death in the country. Despite the devastating effects, approximately 21% of US adults continue to smoke. Certain subgroups of smokers — such as those with medical illnesses — are particularly vulnerable to the adverse health effects of tobacco use and warrant special consideration.

Smoking after diagnosis

Smokers with medical illnesses who do not quit have higher incidence of further complications and progression of disease than those who quit, and smokers with cancer diagnoses continue to smoke at high rates. As many as 60% of patients with lung cancer or head and neck cancers are smokers, and nearly half of them continue to smoke after their diagnosis.

Although a new diagnosis of cancer can serve as an impetus to try to quit, it is no guarantee for success. Patients with diagnoses of cancer who continue to smoke have higher overall mortality (eg, HR of 3 for lung cancer); high rates of morbidity; poorer response to treatments such as surgery, radiation and chemotherapy; higher recurrence of primary disease (eg, HR of 2 for lung cancer); and higher rates of subsequent malignancy.

Life-table modeling for a 65-year-old smoker with early-stage non–small cell lung cancer demonstrates a 33% 5-year survival vs. 70% survival if the person quits smoking. Stopping smoking has a greater impact on survival — with fewer side effects — than many treatment options available to oncology patients. Furthermore, continued smoking affects treatment efficacy. Smokers often require higher-dose chemotherapies and experience greater side effects from radiation. They also are more likely to experience surgical and anesthesia-related complications, including impaired lung function and poor wound healing.

Considering these overwhelming facts, why would someone continue to smoke after a cancer diagnosis?

Despite popular belief, smoking is not merely a bad habit that someone can give up easily. Tobacco smoke is one of the most addictive substances in our society, and the natural history of tobacco dependence is one of frequent relapse and remission.

It is critical that we view tobacco dependence as a chronic condition, like we do other medical conditions such as diabetes. This includes the way we view tobacco dependence treatments and the utilization and insurance coverage for these treatments. Fortunately, evidence-based treatments exist — as outlined by the US Public Health Service (PHC) Clinical Practice Guidelines — and are widely available in many modalities.

Poor treatment utilization

Experts suggest that tobacco-control efforts must focus on increasing demand for and use of effective cessation treatments. Some have explored factors that influence utilization in the general population; however, they generally have focused on system-level factors and policy implications, and none focus on specifics of smokers with cancer.

Despite the demonstrated benefit, only a minority of smokers with cancer utilize treatment in their quit attempts. Studies demonstrate high rates of unaided quit attempts and low treatment utilization in the range of 22% to 33%. The most recent — a 2011 study conducted by Mary E. Cooley, PhD, RN, a nurse scientist at Dana-Farber Cancer Institute, and colleagues — demonstrated that only 30% smokers with cancer were interested in treatment programs and only 19% used cessation medications, with no significant increase in rates of medication usage during the past 5 years.

Treatment principles based on the US PHS Clinical Practice Guidelines have been proven safe and effective, even with highly dependent smokers and those with medical illness. Despite theoretical effects of nicotine on cancer growth, pharmacotherapy, even in smokers with cancer, is considerably safer than continued smoking. 

Smokers with cancer have unique challenges to cessation, including high psychological distress, high nicotine dependence, pressure for abrupt cessation, low self-efficacy, fatalistic beliefs, knowledge deficits and negative social support. Despite these factors, smokers with cancer are significantly motivated to quit.

Although some researchers have examined characteristics related to enrollment in clinical trials, no one has evaluated beliefs and attitudes toward tobacco dependence treatment in a “real-world” setting. Trial data on smokers with cancer fail to demonstrate how these smokers perceive their smoking and why they do not utilize available quit resources. That area needs further exploration.

The role of health care providers

Health care providers play a key role in the identification, assessment and treatment of smokers, and they have contact with approximately 70% of all smokers each year in the United States. Physician counseling, combined with pharmacotherapy and follow-up, increase quit rates. However, data consistently demonstrate that physicians’ rates of counseling are not optimal.

We as health care providers can be a critical component to effective tobacco dependence treatment for smokers with cancer. We need to understand the benefits of cessation on the cancer outcomes for these patients, and we must be aware of the treatment resources available in our communities.

In order to best deliver care to our patients, health care providers could:

• Become familiar with clinical practice guidelines for tobacco dependence treatment (www.ahrq.gov/clinic/tobacco/tobaqrg.htm).
• Incorporate brief interventions into every clinical encounter (Ask, Advise, Assess, Assist, Arrange, or Ask, Advise, Refer).
• Utilize treatment resources. To find treatment specialists in your area, go to www.attud.org. Nationally, call 800-QUIT-NOW or go to www.smokefree.gov.
• Seek out tobacco training for health care providers (http://attudaccred.org/programs).

Many prestigious cancer centers throughout the country have taken on the issue of tobacco dependence treatment as part of their mission and research activities. Only through the continued commitment of effort and resources can these cancer centers hope to significantly improve the health and well-being of smokers with cancer.

Considering that no other single intervention can reduce cancer mortality more than tobacco cessation, this goal should be part of the mission of every organization devoted to reducing the public health impact of cancer.

— Michael Steinberg, MD, MPH, FACP, is director of the Tobacco Dependence Program at the University of Medicine and Dentistry of New Jersey. He is a general internist with dual appointments at the UMDNJ-Robert Wood Johnson Medical School and UMDNJ-School of Public Health. He also is a HemOnc Today Editorial Board member.

Disclosure: Dr. Steinberg reports no relevant financial disclosures.