Integrated care ‘best treatment option’ for smoking cessation during lung cancer screening
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Key takeaways:
- Integrated care of nicotine replacement, pharmacotherapy and counseling proved most durable for smoking cessation.
- Quitline referral and nicotine replacement preferred for screening sites with fewer resources.
Integrated care involving medication and intensive counseling showed effectiveness for smoking cessation among adults undergoing screening for lung cancer, the results of a randomized clinical trial showed.
However, some of the other treatments assessed in the study may be viable —and even preferable — for certain lung cancer screening environments depending on their size and resources, the researchers pointed out.
According to Paul M. Cinciripini, PhD, a professor at the University of Texas MD Anderson Cancer Center, and colleagues, past analyses have shown that smoking cessation interventions conducted during the lung cancer screening process settings have shown greater effectiveness compared with those done during routine primary care, with more intensive interventions being the most effective.
However, “there have been no studies, to our knowledge, comparing referral of patients undergoing [lung cancer screening]directly to a standard quitline vs. other treatments with varying levels of intensity and integration into the [lung cancer screening] health care environment,” they wrote in JAMA Internal Medicine.
In the trial, researchers randomly assigned 630 participants (50.8% men; mean age, 59 years) who smoked a median of 20 cigarettes a day to one of three tobacco treatment interventions:
- quitline referral and 12-week nicotine replacement therapy (QL group);
- quitline referral and 12-week nicotine replacement therapy or medication prescribed by a lung cancer screening clinician (QL+ group)
- integrated care including 12-week nicotine replacement therapy or prescription pharmacotherapy and counseling by tobacco treatment specialists in the lung cancer screening setting (IC group).
Biochemically verified 7-day point prevalence abstinence at 6 months served as the study’s original primary outcome but was changed to self-reported abstinence throughout because of COVID-19 pandemic restrictions.
The researchers found that the rate of abstinence at 6 months appeared highest among the IC group (32.4%), followed by the QL+ (27.6%) and QL (20.5%) groups.
They reported significant differences in abstinence at 3 months between the IC and QL (OR = 1.75; 95% CI, 1.15-2.66) and QL+ (OR = 1.58; 95% CI, 1.05-2.4) groups, while IC continued to outperform QL at 6 months (OR = 1.86; 95% CI, 1.19-2.89).
QL and QL+ did not significantly differ from each other at either 3 or 6 months.
In the study’s Bayesian analysis, IC also showed a higher probability of positive absolute risk differences (ARDs) in abstinence at 3 months vs. QL and QL+ with 99% and 98% probability of ARDs, respectively.
IC’s probability of positive ARDs vs. QL remained at 99% at 6 months, but its probability at that time vs. QL+ dropped to 86%.
Cinciripini and colleagues acknowledged that the study cohort comprised primarily non-Hispanic white individuals. Thus, “caution is needed when generalizing to more diverse populations,” they wrote.
The results show that the IC intervention “provides the best treatment option” in lung cancer screening settings that can support integrated treatment specialists, they added.
Meanwhile, “both QL and QL+ would be viable options” for small lung cancer screening settings that may not have the resources for an integrated approach, they wrote.
“The QL+ option might be preferred because clinicians could be trained to use smoking cessation medications and raise the odds of quitting. In the absence of a trained clinician, direct referral to the state QL can be used to support smoking cessation.”
Cinciripini and colleagues concluded that the integrated model may be the best option for quitting and ultimately improving health outcomes even in other settings, “such as post-traumatic stress clinics, treating patients with cancer, or those with acute [CVD], diabetes, or chronic obstructive pulmonary disease.”
Perspective
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This study highlights several of the foundational tools in tobacco cessation programs. The quit line (1-800-QUIT-NOW) remains a crucial point of access across the nation for those struggling with tobacco addiction. In combination with this service, nicotine replacement therapy and medications like varenicline (Chantix) and bupropion (Wellbutrin) are the mainstays of treatment. However, in addition to these tools, the study by Cinciripini and colleagues highlights the importance of trained tobacco treatment professionals for the best chance of helping patients stop smoking and stay abstinent.
Trained tobacco treatment professionals use not only the resources of the quit line and medications, but also focus on other causes of continuing tobacco use in addition to nicotine addiction. This includes intensive counseling, evaluation of psychological and social causes of smoking and development of both a medical plan for treatment and a behavioral plan that is individualized for each patient.
With lung cancer being one of the most common cancers around the world, smoking cessation is more important now than ever before. Exactly like the researchers at MD Anderson, Temple Health's – Fox Chase Cancer Center Tobacco Treatment Program is a systemwide resource for all Temple and Fox Chase patients and practitioners. Specially trained tobacco treatment providers see patients mostly via telemedicine, providing ease of access to the program, with an additional program to supply free nicotine replacement therapy for those patients who are not covered. In addition to evidence-based comprehensive tobacco cessation, there is considerable research being conducted in this area focusing on new strategies and approaches to improving tobacco cessation.
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