Physician's Weekly Article - Helping Patients Defeat Their Smoking Addiction

       Effective assessment and management of physical, behavioral, and psychological factors can help physicians make smoking cessation a realistic goal for their patients.

      Cancer patients who continue to smoke are at increased risk for substantial adverse effects on treatment effectiveness, overall survival, and development of other cancers. Studies have demonstrated that most patients who try to quit will start up again within the first 3 months. Smoking cessation interventions can be particularly challenging because treatment strategies may need to address complex psychological comorbidities. As a result, many physicians fail to assess and treat tobacco use in accordance with the U.S. Department of Health and Human Services’ smoking cessation guidelines. They often lack time and appropriate counseling skills, believe that smoking cessation discussions are ineffective, and have concerns about intruding on patients’ privacy.

      According to Maher A. Karam, MD, effective smoking cessation involves managing physical symptoms as well as psychological issues. “Physical discomfort is part of the cancer experience for all patients,” he says, “but for smokers, physicians also need to focus on motivation to quit. We know that patients who smoke often have concurrent psychiatric problems, such as depression or anxiety, and may have heavy drinking or dependence on alcohol and/or addiction to other substances. Taking these factors into account and providing appropriate treatment/management increases physicians’ efficacy in producing a successful smoking cessation outcome.”

      Defining the Physician’s Role

      University of Texas M. D. Anderson Cancer Center experts note that patients who quit smoking experience improved cancer outcomes; they have fewer treatment complications, lower surgical infection rates, and decreased potential for recurrence or development of a secondary tumor when compared with patients who continue to smoke, especially when exposed to radio- or chemotherapy. A literature review on smoking cessation and cancer, published in the January 1, 2006 issue of Cancer, suggested that motivation to quit is highest following an initial diagnosis. Physicians who focus on this window of opportunity can help up to 70% of patients quit within 1 year.

      Although 70% of patients who smoke say they would like to quit, only 6% quit without assistance annually and only 4.2% quit without assistance on any one try. “Even something as short as a 3-minute smoking cessation intervention can be effective in some cases,” says Dr. Karam. “Physicians should assess tobacco use at every visit, discuss patients’ motivation to quit, and avoid judgments as it only increases the guilt and shame feelings that patients with cancer feel. Patients may need repeated encouragement and information about the benefits of quitting. Helping patients target and stick to a quit date is especially important, and every effort should be made to inform patients about cessation strategies, including ongoing contact to prevent relapse. These critical steps, in addition to use of pharmacotherapy, can help physicians make smoking cessation a realistic goal for cancer patients [Table 1].”

      Smoking Cessation: A Team Effort

      The Tobacco Treatment Program at M. D. Anderson, established in 2006 by Paul Cinciripini, PhD (Director) and Janice Blalock, PhD (Assistant Director), involves a team of psychologists, social workers, an advanced practice nurse and an addiction psychiatrist to optimize smoking cessation efforts. “Our goal,” Dr. Karam explains, “is to address all the barriers to quitting. It’s important to discern whether or not patients have low motivation, a psychiatric disorder, another substance dependence, a spouse or family member who still smokes, or lack of financial resources to pay for a smoking cessation program.” The program, including all smoking cessation medications, is completely free up to 3 months—an extremely unique and important feature, Dr. Karam notes. “The team identifies psychiatric comorbidities, alcohol use, and motivation to quit through an assessment questionnaire that evaluates these variables before a patient sees a clinician.” The program is offered to any M. D. Anderson patient who is a current smoker or recently quit within last 12 months.

      Current studies help the Tobacco Treatment Program tailor interventions to patients’ specific needs and focus on how to achieve tobacco-cessation goals, according to Dr. Karam (Table 2). “Patients are referred to me if they need help with other addictions, or they have comorbid psychiatric conditions, or they fail our standard approach with smoking cessation. All patients are seen over a 12-week period for 30 to 60 minute sessions. Patients outside our referral area receive assistance by telephone, and medications are sent by mail directly to all patients at no cost. After the first visit, an advanced practice nurse calls within 2 weeks to check on any side effects and to provide further refills and focus on preparing for a quit date. Once they quit, if relapse occurs, the team starts all over again from the beginning. Although not every physician is equipped or funded to deliver these types of intensive services, lessons learned from the program are planned to be communicated in different venues as they can be applied to office-based practice.”

      New Hope for Cancer Patients Who Smoke

      About 24% of cancer patients referred to M. D. Anderson, are smokers or recent quitters within last 12 months. “Of this group, about half were unable to quit either on their own or with medication even after the diagnosis of cancer,” says Dr. Karam. “Among these ‘hard core’ smokers, about 40% have comorbid psychiatric diagnoses such as anxiety, depression, or insomnia; about 30% have alcohol abuse disorder.” Since the start up of the Tobacco Treatment Program, about 850,000 unique patients have been treated and about 7,500 treatment visits delivered so far. Data after 1.5 years show an astonishingly high quit rate by the end of the 12-week intervention. About 60% of patients who were initially ready to quit actually did so. Another 30% of patients who were not quite ready to quit or did not agree to a quit date also managed to quit. Our average quit rate at 12 weeks is 44%, comparing favorably with general rates observed at 8 to 12 weeks in pharmacotherapy studies on smoking cessation with non-cancer motivated volunteers. Moreover, among all smokers who did not quit entirely, we observed a 50% reduction in tobacco use, which is expected to motivate patients further to get to total cessation. Our hope is that the effectiveness of our program will gain momentum and encourage the development of programs alike in other areas throughout the United States. With some added funding and a good plan in place, there may finally be some optimism when it comes to getting our patients to quit smoking.”

      Dr. Karam has indicated to Physician’s Weekly that he has no financial disclosures to report.