By Leah Lawrence
Posted: June 24, 2020
In late February 2020, the U.S. Food and Drug Administration (FDA), American Association for Cancer Research (AACR), and the IASLC held its FDA/CDER-AACR-IASLC Workshop to address the criticality of tobacco use assessment in oncology therapeutic trials.
During this workshop, several speakers discussed the importance of smoking cessation, especially among patients with cancer, and their experience providing tobacco cessation assistance.
According to the 2020 Surgeon General’s Report on Smoking Cessation, although the prevalence of cigarette smoking among American adults is at an all-time low, there are still approximately 34 million adults who smoke in the United States.1 Additionally, research has shown that the majority of cigarette smokers have a desire to quit.
“That means if you meet a tobacco user, chances are that person wants to quit,” said Linda Bailey, JD, MHS, of North American Quitline Consortium, who opened the session on cessation assistance. “Unfortunately, success rate for quits is only a bit more than 7%, and many do not use any evidence-based treatments.”
Healthcare providers have an important role to play in helping people who smoke quit successfully. Surveys among IASLC members showed that although most healthcare professionals know smoking causes adverse outcomes and the majority ask about tobacco use and encourage patients to quit, only a few offer any direct assistance with quitting.2
During her presentation, Ms. Bailey detailed many of the resources available that healthcare professionals can offer to aid patients in their quit attempts.
Community-Based Resources
The two main components to tobacco cessation programs are counseling and medication, Ms. Bailey said. There is also growing evidence on the efficacy of new technologies such as text messages or internet-based interventions.
One of the most popular and effective resources for tobacco cessation remains quit lines. In the United States, there are 53 quit lines: one for every state, the District of Columbia, Guam, and Puerto Rico.
“Each year, state quit lines receive more than one million calls,” Ms. Bailey said.
On its website, the North American Quitline Consortium provides profiles on quit line information for each state that includes hours of operation, supported languages, counseling session topics, web-based services, availability of free or discounted medications, and other services. Each profile also details the state’s provider referral program.
The provider referral program information describes the way that providers can refer patients to the quit lines. All quit lines offer referral by fax. The majority also offer online referral. Each profile details the referral program contact who can help health practices or providers set up a referral program with the quit line.
Outside of quit lines, Ms. Bailey discussed four strategies to encourage patients to seek cessation. The first is the Centers for Disease Control and Prevention national media campaign Tips from Former Smokers.
“When that campaign runs, we see double the call volume to quit lines than we do when it is not running,” Ms. Bailey said. “It is an incredibly effective campaign for encouraging smokers to quit.”
The second strategy is patient resources. For example, there are cessation cards available for distribution to smokers in healthcare settings. The cards typically include a list of telephone numbers for quit line services or have the 1-800-QUIT-NOW number on the front.
The third group of strategies is more provider involved, Ms. Bailey said. For example, one resource is direct referral by clinicians to quit lines. Another is use of the American College of Cardiology Expert Consensus Decision Pathway for Tobacco Cessation Treatment, which is a stepwise guide for addressing cigarette smoking during a routine office visit.3
The last strategy is a fairly new one, Ms. Bailey said. In some cases, quit lines can work with different provider groups to develop tailored protocols that serve the group’s patient population. For example, tailoring cessation strategies for behavioral healthcare providers.
Cessation Integration
After seeing that many patients at his cancer center were having a difficult time quitting smoking and accessing available cessation resources, the session’s next speaker, Matthew Steliga, MD, of Winthrop P. Rockefeller Cancer Institute, made the decision to become a certified tobacco treatment specialist.
“We have a high population of people who smoke and are unable to quit,” Dr. Steliga said. “We know smoking impacts outcomes in a negative way, and we know that some of that can be reduced and mitigated by cessation.”
For example, a 2015 retrospective study by Dobson Amato and colleagues examined the use of a telephone-based cessation service among more than 300 patients with lung cancer.4 Of those patients who were successfully contacted and participated in at least one telephone-based cessation call, more than 40% reported having quit at their last contact. The study also showed a significant increase in survival associated with quitting compared with ongoing tobacco use (HR 1.79; 95% CI [1.14, 2.82]).
“The group of patients who quit had a significant difference in outcome—a survival difference of 9 months,” Dr. Steliga said. “If that was a drug, we would approve it. If that was a surgery, it would be standard of care.”
To begin to incorporate tobacco cessation efforts, Dr. Steliga and colleagues first began to hand out information brochures to patients. However, after a few months, he was discouraged to find some of the brochures in the garbage as he walked out of work.
Next, the practice began efforts to train nurse practitioners as certified tobacco specialists, and cessation counseling was offered as an “opt-in” program. However, approximately half of patients did not opt in, Dr. Steliga said.
In order to encourage more participation, they further adapted the program to be an “opt-out” program.
“We would say, ‘Mr. Jones, as part of your cancer treatment, we are going to get experts to work with you to help you quit smoking. They will be in here in a minute,’” Dr. Steliga said. “Patients could refuse, but very few did.”
A study of this program looked at 275 patients seen over 17 consecutive months.5 All patients were currently smoking and offered the opt-out meeting with the tobacco cessation specialist. Of the 240 patients with follow-up, 2.9% increased their smoking, 23.3% had no change, 29.2% had decreased smoking, and 44.6% had quit.
Dr. Steliga said some questioned the decision to put this cessation counseling into a surgical clinic.
“We are trying to make people’s lives better, healthier, and longer,” he said. “We have four exam rooms, and I can only be in one at a time. Instead of having patients look through old magazines, they now receive face-to-face counseling and make a quit plan they can follow.”
Brief Advice
The session’s final speaker was addiction expert Laura Bierut, MD, of Washington University School of Medicine. Dr. Bierut spoke about the simple and brief advice that Siteman Cancer Center has incorporated into its electronic health records (EHRs).
“As a physician and a psychiatrist, I will say that as soon as we say the word ‘counseling,’ it drives physicians, nurses, and medical assistants to the point of fear,” Dr. Bierut said. “They fear that they do not have the expertise to do counseling.”
Instead, Dr. Beirut calls the counseling baked into the EHR “brief advice.” There is a line that the medical assistants are prompted to say if they enter into the EHR that the patient is a current smoker: “Quitting smoking is one of the most important things that you can do for your health.”
According to Dr. Beirut, they want to inform patients that it is never too late for patients with cancer to stop smoking cigarettes and experience health effects.
Smoking status is so important, in fact, that it should be considered a fifth vital sign, she said. It should be documented in a patient health record and updated at regular intervals. Interventions and quit attempts should also be noted.
Just as important as noting smoking status is offering help. When assessing tobacco cessation programs at Siteman Cancer Center, patient and provider interviews revealed misalignments. For example, patients said they were asked about smoking history but not offered help. Providers said they offered help, but patients were not interested in quitting.
Using what they learned from these interviews, Dr. Beirut and colleagues developed a treatment strategy and began to institute a grassroots effort to embed cessation efforts into treatment. The goals were simple, Dr. Beirut said. Every patient should be assessed, and every smoker should be offered treatment.
Prior to implementing changes, the practice saw approximately 30,000 people in 6 months; the prevalence of smoking was approximately 11%. During this time, only 48% of patients had smoking status assessed compared with 89% after strategy implementation. After the launch of the program, 1.91% of patients were referred to counseling, and 17% were prescribed medication to help them quit compared with 0.72% and 3%, respectively, prior to the program implementation.6
Patients who were treated were three times more likely to quit, Dr. Beirut said. All of this was with a cost-effective, low-burden strategy.
“The enemy is combustible cigarettes, and harm reduction is critical,” Dr. Beirut said. “Smoking cessation after cancer diagnosis extends life. It is never too late.”
References:
1. U.S. Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General. Executive Summary. Accessed April 20, 2020. https://www.hhs.gov/sites/default/files/2020-cessation-sgr-executive-summary.pdf.
2. International Association for the Study of Lung Cancer. Declaration from IASLC: Tobacco Cessation After Cancer Diagnosis. Published September 4, 2019. Accessed April 20, 2020. https://www.iaslc.org/About-IASLC/News-Detail/declaration-from-iaslc-tobacco-cessation-after-cancer-diagnosis.
3. Barua RS, Rigotti NA, Benowitz NL, et al. 2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment. A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. JACC. 2018;72(25):3332-3365.
4. Dobson Amato KA, Hyland A, Reed R, et al. Tobacco cessation may improve lung cancer patient survival. J Thorac Oncol. 2015;10(7):1014-1019.
5. Steliga M, Barone C, Franklin P, et al. Outcomes of smoking cessation counseling in a surgical clinic. J Thorac Oncol. 2019;14(11; suppl 1):S1128.
6. Ramsey AT, Chiu A, Baker T, et al. Care-paradigm shift promoting smoking cessation treatment among cancer center patients via a low-burden strategy, Electronic Health Record-Enabled Evidence-Based Smoking Cessation Treatment. Transl Behav Med. 2019 Jul 17. [Epub ahead of print].
