MAY/JUNE 2008
Volume 14 - No. 2

SRNT Newsletter

MAY/JUNE 2008, Volume 14, Number 2

Treating Smoking Addiction in Patients with a Cancer Diagnosis

by Maher Karam-Hage

Maher Karam-Hage

It is well known by now that many physicians do not assess and treat tobacco use in accordance with the U.S. Department of Health and Human Services' smoking cessation guidelines. There have been many speculations on why that is the case, the most probable causes are: 1) physicians often lack time and appropriate counseling skills, 2) they believe that smoking cessation discussions are ineffective, and 3) they have concerns about intruding on patients' privacy. Unfortunately, cancer patients who continue to smoke are at increased risk for substantial adverse effects on treatment effectiveness, overall survival, and development of secondary cancers after completing treatment for the first one. In this setting, smoking cessation interventions can be particularly challenging because the treatment strategy may need to address complex medical, psychiatric as well as psychological comorbidities. Published data show that patients who smoke often have concurrent psychiatric problems, such as depression and 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 would be expected to increase patients' efficacy in reaching a successful smoking cessation outcome. Patients who quit smoking experience improved cancer outcomes, have fewer treatment complications (e.g. lower surgical and other infection rates). They also have a decreased potential for recurrence or development of a secondary tumor when compared with patients who continue to smoke, especially when exposed to radio- or some chemotherapies. In a review on smoking cessation and cancer, Gritz & colleagues (Cancer 2006) suggested that motivation to quit is highest following an initial cancer diagnosis therefore is seems crucial to emphasize smoking cessation during this window of opportunity and it may help up to 70% of patients quit within 1 year.

The Program at University of Texas M. D. Anderson Cancer Center

Paul Cinciripini

Janice Blalock

The Tobacco Treatment Program at M. D. Anderson, established in 2006 by Paul Cinciripini, PhD (Director) and Janice Blalock, PhD (Assistant Direc- tor), involves a team of psychologists, social workers, an advanced practice nurse (APN) and an addiction psychiatrist Maher Karam-Hage, MD (Associ- ate Medical Director) to optimize smoking cessation efforts. The program’s goal is to address all the barriers to quitting. It’s important to discern whether or not patients have low motivation, a psychiatric disorder, dependence on another substance, a spouse or family member who still smokes, or lack of financial resources to attend the tobacco program. The program, including all smoking cessation medications, is delivered to the patient at no cost for up to 3 months—an extremely unique and important feature, which allows all MD Anderson patients an easy access to the tobacco cessation help that they need. The team identifies psychiatric comorbidities, alcohol and other substance use, and motivation to quit through an assessment battery that evaluates these variables before a patient gets to see a clinician. The program is offered to any M.D. Anderson patient who is a current smoker or has recently quit within the last 12 months.

Current and future studies are planned to help the Tobacco Treatment Program tailor interventions to patients’ specific needs and focus on how to achieve tobacco-cessation goals. Patients are referred to the addiction psychiatrist if theyneed help with other addictions, have comorbid psychiatric conditions, or fail our standard approach with smoking cessation. All patients are seen over a 12-week period for approximately eight 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 or second visit a nurse contacts all patient prescribed tobacco cessation medication within 2 weeks to check on any side effects and to provide further refills and to helps patients to focus on preparing for a quit date. Even after abstinence is achieved, the patient is followed through long-term appointments for a year to provide relapse prevention support. If relapse occurs, then the team works with the patient to re-enter them into the program to start another quit attempt. Although not every health care procvider 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 practices, including 4 posters planned to be presented at the annual meeting of the Society of Research on Nicotine and Tobacco (SRNT) in Portland Oregon February 2008.

Finally, About 24% of cancer patients referred to M.D. Anderson are estimated to be smokers or recent quitters within the 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. Among these ‘hard core’ smokers, our data shows that about 40% have comorbid psychiatric diagnoses such as anxiety, depression, or insomnia; about 30% have an alcohol use disorder. The Tobacco Treatment Program have recently celebrated its 2 years anniversary and it has so far treated in excess of 1,100 unique patients and about 8,500 treatment visits have been delivered so far. An analysis of data after a year and a half of operations showed a remarkable high quit rate by the end of the 12 weeks of treatment intervention. About 60% of patients who were initially ready to quit (had agreed to fix a quit date) actually did quit. Another 30% of patients who were not quite ready to quit or did not agree to a quit date also managed to quit at the 12 weeks. Our mean quit rate across both groups, at 12 weeks, was 44%. This rate compares favorably with the 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 thought and 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 similar programs in other medical and cancer centers throughout the United States. With some dedicated funding and a good plan in place, this kind of program can be replicated so patient who desperately need to stop using tobacco would get the help they need.

References

Gritz E, Fingeret M, Vidrine D, et al. Successes and failures of the teachable moment: smoking cessation in cancer patients. Cancer. 2006;106:17-27.

Fiore M, Bailey W, Cohen S, et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services.

Public Health Service. October 2000. Go to www.ahrq.gov/path/tobacco.htm.

Thomas S. Smoking cessation part 1: brief interventions. Nurs Stand. 2007;22:47-49.

Shiffman S. Nicotine replacement therapy for smoking cessation in the “real world”. Thorax. 2007;62:930-931.

Stack NM. Smoking cessation: an overview of treatment options with a focus on varenicline. Pharmacotherapy. 2007;27:1550-1557.

Mallin R. Smoking cessation: integration of behavioral and drug therapies. Am Fam Physician. 2002;65:1107-14. Available at www.aafp.org/afp/.

Quitting Smoking: Why to Quit and How to Get Help. National Cancer Institute. 2007. www.cancer.gov/cancertopics/.