Tobacco cessation program empowers patients at ‘teachable moment’ before cancer surgery
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Although smoking cessation is known to benefit patients with cancer, obstacles exist at the patient, clinician and institutional levels, according to a poster presentation at American Association for Cancer Research Annual Meeting.
“Even if the patient says, ‘I want to do it,’ and the physician says, ‘Let’s go ahead,’ if the institution doesn’t have a smoking cessation program with trained specialists who can help the patient navigate the smoking cessation experience, it can be very difficult,” Cary A. Presant, MD, professor in the department of medical oncology and experimental therapeutics research at City of Hope, said in an interview with Healio.
To address this obstacle, Presant and his colleagues at City of Hope developed the Personal Pathway to Success program, which allows patients with cancer to choose from among 27 different smoking cessation tools. Because smoking is linked to adverse surgical outcomes, Presant and his colleagues piloted the program at the preoperative anesthesia testing clinic. They assessed patients for acceptance of smoking cessation, as well as for follow-through.
Among 54 patients offered the program, 23 completed counseling. As a result of the program’s availability, initial patient interest in smoking cessation increased from less than 10% to more than 50%, results showed.
Presant spoke with Healio about the challenges inherent to smoking cessation, the shortcomings of a “one-size-fits-all” approach and the “teachable moment” that presents itself in the preoperative anesthesia testing clinic.
Healio: What are some of the obstacles to successful smoking cessation for patients with cancer?
Presant: One obstacle occurs at the patient level. The patient might be concerned about getting their cancer treated and controlled or cured and doesn’t want to bother with smoking cessation. Other patients might say, “I use smoking to relieve stress, so I don’t want to do smoking cessation right now.” They might have tried before and failed, and might be reluctant to try again.
There also are obstacles involving the physician. Many physicians don’t know how to do smoking cessation, and they’re not motivated because they don’t realize the benefits. Often, they lack the knowledge about increased cure, remission and survival benefits of 30% with cessation. Frequently, they might say they are too busy.
Then there are the institutional stumbling blocks. Institutions need to have a smoking cessation program with an electronic medical record to enter the orders for smoking cessation and efficiently get patients to the right place. This is especially important in large networks within an institution, which are very common.
Another issue is that smoking cessation has never been well-funded by insurance programs. So, physicians often say, “Why would I want to spend time doing this? We’re not being paid adequately for this.” We’re seeing a need to use funding mechanisms such as the new Moonshot program to provide increased support for smoking cessation programs and appropriate use of CPT codes 99406-7 to reimburse for counseling.
Healio: Your program allows patients to choose from 27 different smoking cessation tools. How is this helpful in encouraging patients to quit?
Presant: It overcomes their initial unwillingness to consider smoking cessation. It gets them involved in saying yes, and it empowers them to use their personal preferences to guide their smoking cessation trajectory. It really is a trajectory, not a moment in time. It’s a lifelong process in which the patient is overcoming an addiction.
Healio: You offer these options for the smoking cessation tools during the preoperative anesthesia testing clinic visit. Is this a time when someone would be especially receptive to this message?
Presant: Yes. Certain times in a patient’s course with cancer are teachable moments. We need to focus on these moments as times when patients can accept new information and new strategies to help them avoid smoking. This is especially important in preoperative anesthesia teaching clinics. Smokers have a much higher rate of complications after surgery. They have infections, poor wound healing and greater risk for hospital readmission. The preoperative time point is when the patient is more likely to say, “Yes, I’m going to follow the direction of my doctor.” This has benefits for the operative period. It also has benefits as we follow up with postoperative radiation, chemotherapy or immunotherapy. All of these are better facilitated by smoking cessation.
Healio: How did your study assess the Personal Pathway to Success program, and what did you find?
Presant: We evaluated our tools to find out which ones patients liked and which they most often chose. We found certain tools we consider to be essential. One is some type of counseling program, usually by telehealth or sometimes by video or telephone. Sometimes, patients feel they can relate better with a counselor in a face-to-face setting.
Another very important tool is medication support. Very often, it is a nurse practitioner who provides the prescription for a patient. Other times, it’s the medical oncologist or a radiation oncologist. It’s important in our program that we provide educational tools to patients to help them understand their medications. We also provide information to physicians to help them understand which medications and doses are optimal for these patients.
Patients do not like educational brochures. Only about 16% reported that they wanted to use a brochure. However, about 75% reported liking educational videos. They noted an overwhelming feeling that, after watching the video, they were motivated to stop smoking and they had the knowledge to make their plan a success.
When we combined those essential tools, we found that about 96% of the patients utilized at least one of those types of interventions. Of course, if they choose just one, then we tobacco treatment specialists can nudge them to use another.
We also found support groups helped patients stay motivated and that it helped to involve a patient’s family and friends. We realized that people who are smoking often have other smokers around them. It is helpful to have a support group that is free for our patients and multilingual.
We have seen about half of our patients utilize state resources, like quit lines that they can use telephonically and text support on mobile phones.
We see so many different approaches to smoking cessation, and because of this, we have a menu. More than half the patients accepted smoking cessation, whereas normally only about 20% accept smoking cessation. Now, our strategy is to follow these patients longer term and determine how effective it has been at later time points. We will look at 3 months, 6 months, 12 months out. So, far, it looks like it is working very well.
Healio: Why is smoking cessation so important in patients with cancer?
Presant: Smoking cessation is the fourth pillar of cancer care. We have surgery, radiation, chemotherapy and immunotherapy, but smoking cessation is essential, too. The outcomes of patients with cancer who have gone through smoking cessation are 30% better in terms of cure rate, response rate and quality of life compared with those who continue to smoke. So, we see a big benefit, as we see with adjuvant hormonal therapy or adjuvant chemotherapy.
For more information:
Cary A. Presant, MD, can be reached at City of Hope, 1500 E. Duarte Road, Duarte, CA 91010; email: cpresant@coh.org.
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Presant CA, et al. Poster LB553. Presented at: American Association for Cancer Research Annual Meeting (hybrid meeting). April 8-13, 2022.
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