Smoking Intervention in Cancer Patients
Surprisingly few smoking intervention studies have been conducted with cancer patients. Many patients report quitting smoking at the time of diagnosis, and many others have comorbidities that prevent enrollment in clinical trials, yet little is known about routine smoking cessation services in an oncology setting. Thus, a smoking cessation feasibility study reported on implementation issues. In this study, 14,514 adult cancer patients were screened as potential participants, with fewer than 2% of patients determined to be eligible. Barriers to enrollment and exclusion criteria included the following:
- Nonsmoker status (83%).
- Contraindicated medical history (e.g., serious cardiovascular problem) (5%).
- Not interested in quitting smoking (4%).
- Current psychiatric condition (e.g., alcohol dependence, any Axis I disorder) (0.1%).
- Other (e.g., unreachable by phone, too far to travel, died, non-English speaker, current medication contraindicated) (7.2%).
Eighty-four percent of eligible patients enrolled. Patients who declined enrollment were more likely than those who enrolled to have advanced disease. Patients who enrolled had extensive smoking histories (mean, 38 years), scored very high on measures of nicotine dependence, and averaged about seven drinks per week; about one-quarter of enrollees reported clinical levels of depressive symptoms. Researchers concluded that integrating a smoking cessation program into routine clinical care is feasible, although challenging, and that particular attention should be given to the subpopulation of smokers who also experience depression. Other studies also suggest lower cessation rates in patients with depression and alcohol use disorders.[2,3]
Another study found that when consistent intervention was provided to a group of patients with head and neck cancer, about 65% were able to quit and remain abstinent, including about one-half of patients who expressed little interest in quitting at baseline.[Level of evidence: I] A large intervention study with head and neck cancer patients used surgeon- or dentist-delivered advice to stop smoking, contracted quit dates, written materials, and booster advice sessions. Partially because of a high drop-out rate, a significant intervention effect was not detected, although differences were in the expected direction. A similar study [Level of evidence: I] also failed to find beneficial effects for very brief (<5 minutes) physician-delivered interventions based on the Ask, Advise, Assist, Arrange model outlined below. More than 400 cancer patients with a range of diagnoses were randomly assigned to receive either intervention or usual care. Approximately one-half had been diagnosed within the previous 6 months; 46.3% had tried to quit in the previous 6 months; and 84% were considering quitting in the following 6 months. Patients randomly assigned to the intervention group acknowledged receiving advice and resources from their physician consistent with the protocol; however, there were no significant differences in quit rates at either 6-month follow-up (11.9% vs. 14.4%) or 12-month follow-up (13.6% vs. 13.3%). Patients were more likely to quit smoking if they had been diagnosed with head and neck cancer or lung cancer, were lighter smokers, expressed a strong desire to quit, and used additional intervention resources. These results suggest that very brief physician counseling for this high-risk group is not adequate to improve quit rates.
A case-controlled retrospective study [Level of evidence: III] examined the effects of referral to a nicotine dependence center for more than 200 smokers diagnosed with lung cancer compared with smokers without a lung cancer diagnosis. Most lung cancer patients were less likely to have made previous attempts to quit smoking but expressed higher motivation to quit than did individuals without lung cancer. Although the likelihood of being abstinent at 6 months postintervention was higher among lung cancer patients (22% vs. 14%), after adjusting for demographic variables and level of motivation, there was no statistically significant difference. Patients who were closer to diagnosis at the time of intervention were far more likely to be abstinent at 6 months (27.3% vs. 0% for 3–6 months vs. 7% for >6 months, P = .01). In general, a brief smoking intervention consisting of approximately 1 hour of tailored intervention, including prescription of pharmacologic treatment, showed relatively little impact in this high-risk population. However, referral sooner after diagnosis may increase the likelihood of quitting. This study is limited by the self-selection of patients and lack of a nonintervention comparison group.
Considerable work has been done, however, with other patient groups—particularly cardiac patients—in establishing the valuable role of physicians and other health care providers in providing smoking intervention in the context of medical care. Specific recommendations for intervening in tobacco use have been published in several contexts. On the basis of outcomes from six major clinical trials of physician-delivered smoking intervention conducted in the late 1980s, the Ask, Advise, Assist, Arrange model was developed. In this model, the physician provides a brief intervention that entails asking about smoking status at every visit, advising abstinence, assisting by setting a quit date, providing self-help materials, recommending the use of nicotine replacement therapy, and arranging for a follow-up visit. See the list below for brief and expanded intervention outlines. The Patient-Centered Counseling Key Elements list below provides detailed questions that may be asked in the assist phase in a patient-centered counseling format that is brief enough (5–7 minutes) to be delivered within the context of a usual office visit.[Level of evidence: I]
These recommendations form the core of the Public Health Service–sponsored Clinical Practice Guideline [Level of evidence: IV]; that extended the recommendations by strongly supporting the value of referral to more intensive counseling. Furthermore, in addition to the documented value of nicotine replacement therapy (using gum, lozenge, patch, nasal spray, or inhaler), there is now clear evidence for the value of the antidepressant bupropion HCl (Wellbutrin SR and Zyban), 150 mg twice a day, as an adjunct for treatment; however, these adjunctive pharmacological treatments have not been tested in cancer patients. Individuals should be advised to check with their physicians.
Not all smokers are equally motivated to stop smoking. One of the most useful models for physicians in understanding the motivational issues in stopping smoking and actually quitting is the Stages of Change Model. Most individuals attempting to change a complex behavior such as smoking go through several predictable stages, from precontemplation to contemplation to preparation and, finally, to action. One of the goals of brief physician counseling is to move patients along these stages, until they are more motivated to quit. In addition, especially for first-time quitters, relapsing and cycling through these stages one or more times is common, until the person develops better behavioral skills.
The most common triggers for relapse are stressful situations and social triggers for smoking. One study found that the patterns of relapse in head and neck cancer patients were comparable to patterns of relapse in quitters in the general population.[Level of evidence: II] Smokers should be encouraged to anticipate such situations and develop strategies for handling them, as part of developing a new identity as a nonsmoker. It may take more than a year for even motivated smokers to successfully make these changes. The Stages of Change Model is well described and summarized  and is outlined as part of the Ask, Advise, Assist, Arrange Key Elements list below. Other important information such as smoking history (e.g., amount smoked or previous attempts to quit) can be efficiently collected by asking patients to complete a brief set of self-assessment forms in the waiting room. Nicotine addiction can be assessed using the Fagerstrom Test for Nicotine Dependence (FTND), and behavioral patterns (e.g., tendency to smoke when under stress) can be assessed using the online booklet titled Clearing the Air. When talking with patients about smoking cessation, providers can use a fact sheet available from the Centers for Disease Control and Prevention.
Psychiatric disorders and alcohol abuse may be complicating factors in the treatment of smoking, regardless of the population. Smoking prevalence is notably higher among those with mental or alcohol disorders,[13,14] and response to treatment is poorer.[15,16]
A comprehensive longitudinal study  of all patients (N = 1,425) seen over a 3-year period at the MD Anderson Cancer Center Tobacco Treatment Program identified individuals with major depression (n = 194), an anxiety disorder (n = 53), alcohol abuse (n = 92), or combinations of these disorders (n = 255), with the remainder (n = 831) having no psychiatric diagnosis. Across groups, individuals smoked an average of one pack per day. Patients received an individually tailored behavioral intervention, generally consisting of an in-person initial evaluation and an average of eight treatment sessions over 3 to 4 months, either in person or by phone, with follow-up at 6 months. Smoking-related pharmacotherapy was part of treatment for 88% of participants; about 15% also received a consultation with the program's addiction psychiatrist.
Individuals with no psychiatric diagnosis had abstinence rates of 44% at the end of the program and 45.1% at 6 months. Abstinence rates for clinical groups at 6 months varied, as follows:
- 30.2% for those with combined anxiety, depression, and alcohol abuse.
- 33.7% for those with alcohol abuse alone.
- 37.6% for those with major depression.
- 45.3% for those with only an anxiety disorder.
Regardless of the diagnosis, the best predictor of extended abstinence was the FTND (overall average score, 4.9 [standard deviation, 2.2]; group range, 4.7 [no diagnosis] to 5.4 [major depression]). The overall conclusion is that in an intensive comprehensive program for cancer patients who are smokers, such as the program offered at MD Anderson, individuals with an anxiety disorder are likely to do as well as individuals without any diagnosis, but those with major depression or alcohol abuse may do more poorly, particularly if their FTND scores are higher.
Tailoring intervention for specific populations may also be important, although this has not been examined specifically in cancer patients. A study of the effects of self-help intervention materials designed for an African American population showed higher quit rates (25%) among those who received the tailored materials than among those who received the standard materials (15.4%) at 12 months postintervention.[Level of evidence: I]
Other investigators have begun to examine intervention approaches specific to patients at high risk of developing lung cancer, through the use of genetic biomarker feedback (presence of the CYP2D6 genetic abnormality, which increases the risk of developing lung cancer twofold to fourfold) in otherwise healthy smokers. Adding information on genetic risk of cancer to the usual counseling approaches increased initial quit rates significantly, but this effect was not maintained; such an approach may be a useful motivational component to add to a more comprehensive intervention but may not be sufficient in itself.[Level of evidence: I]
Ask, Advise, Assist, Arrange Key Elements
- Minimal assessment: Screen for smoking status at every visit or at admission.
- Augmented assessment: Assess characteristics of smoking history and patterns.
- Amount smoked.
- Quit history.
- Stage of change:
- Precontemplator: Is not seriously considering stopping smoking.
- Contemplator: Is seriously considering stopping within 3 to 6 months.
- Preparation: Is seriously considering stopping within the next week to month, and has already made changes such as cutting back.
- Action: Has recently stopped smoking (within last 6 months).
- Relapse: Has quit for at least 48 hours but is smoking again.
- Maintenance: Has quit for at least 6 months but may still be vulnerable to a relapse up to 1 year.
- Nicotine addiction: Fagerstrom Test for Nicotine Dependence.
- Behavioral patterns: Online booklet titled Clearing the Air.
- Minimal advice: “As your physician, I must advise you that smoking is bad for your health, and it would be important for you to stop.”
- Augmented advice: “Because of your (__________) condition, it is particularly important for you to stop. If you stop now, (briefly educate patient about basic health benefits from quitting).”
- Minimal assistance: Provide self-help materials; assess interest in quitting; assess interest in and appropriateness of pharmacological aids.
- Augmented assistance: Provide brief 5- to 7-minute patient-centered counseling. See the list below for an outline of the counseling content.
- Arrange follow-up support:
- Minimal follow-up support: Arrange for single follow-up contact by visit or by telephone in about 2 weeks; provide referral to a smoking counselor or group.
- Extended follow-up support: Establish quit-smoking contract with quit date. Arrange three or more follow-up contacts by visit or by telephone.
Patient-Centered Counseling Key Elements
- Basic question:
- “How do you feel about your smoking?”
- Follow-up questions:
- “How do you feel about stopping smoking?”
- “Have you ever tried to stop before?” “What happened?”
- “What do you like about smoking?”
- “What do you not like about smoking?”
- Basic question:
- Anticipated problems:
- Basic question:
- “What problems will you have if you stop smoking?”
- Follow-up questions:
- “Anything else?”
- According to My Quit Journal (available in the online booklet titled Clear Pathways), your craving level was highest when you were (_____). How do you think you can handle that type of situation?”
- Basic question:
- Resources for coping with problems:
- Basic question:
- “How do you think you can handle that?”
- Follow-up questions:
- “What else could you do?”
- “How do you expect your (family/spouse/friends) to help you?”
- Basic question:
- Martinez E, Tatum KL, Weber DM, et al.: Issues related to implementing a smoking cessation clinical trial for cancer patients. Cancer Causes Control 20 (1): 97-104, 2009. [PUBMED Abstract]
- Schnoll RA, Martinez E, Langer C, et al.: Predictors of smoking cessation among cancer patients enrolled in a smoking cessation program. Acta Oncol 50 (5): 678-84, 2011. [PUBMED Abstract]
- Blalock JA, Lam C, Minnix JA, et al.: The effect of mood, anxiety, and alcohol use disorders on smoking cessation in cancer patients. J Cogn Psychother 25 (1): 82-96, 2011.
- Gritz ER, Carr CR, Rapkin D, et al.: Predictors of long-term smoking cessation in head and neck cancer patients. Cancer Epidemiol Biomarkers Prev 2 (3): 261-70, 1993 May-Jun. [PUBMED Abstract]
- Schnoll RA, Zhang B, Rue M, et al.: Brief physician-initiated quit-smoking strategies for clinical oncology settings: a trial coordinated by the Eastern Cooperative Oncology Group. J Clin Oncol 21 (2): 355-65, 2003. [PUBMED Abstract]
- Sanderson Cox L, Patten CA, Ebbert JO, et al.: Tobacco use outcomes among patients with lung cancer treated for nicotine dependence. J Clin Oncol 20 (16): 3461-9, 2002. [PUBMED Abstract]
- Glynn TJ, Manley MW, Pechacek TF: Physician-initiated smoking cessation program: the National Cancer Institute trials. Prog Clin Biol Res 339: 11-25, 1990. [PUBMED Abstract]
- Ockene JK, Kristeller J, Goldberg R, et al.: Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial. J Gen Intern Med 6 (1): 1-8, 1991 Jan-Feb. [PUBMED Abstract]
- Prokhorov AV, Hudmon KS, Gritz ER: Promoting smoking cessation among cancer patients: a behavioral model. Oncology (Huntingt) 11 (12): 1807-13; discussion 1813-4, 1997. [PUBMED Abstract]
- Fiore MC, Jaén CR, Baker TB, et al.: Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians. Rockville, Md: Public Health Service, U.S. Department of Health and Human Services, 2009. Also available online. Last accessed June 12, 2014.
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- Gritz ER, Schacherer C, Koehly L, et al.: Smoking withdrawal and relapse in head and neck cancer patients. Head Neck 21 (5): 420-7, 1999. [PUBMED Abstract]
- Lawrence D, Mitrou F, Zubrick SR: Smoking and mental illness: results from population surveys in Australia and the United States. BMC Public Health 9: 285, 2009. [PUBMED Abstract]
- Lasser K, Boyd JW, Woolhandler S, et al.: Smoking and mental illness: A population-based prevalence study. JAMA 284 (20): 2606-10, 2000 Nov 22-29. [PUBMED Abstract]
- Breslau N, Peterson E, Schultz L, et al.: Are smokers with alcohol disorders less likely to quit? Am J Public Health 86 (7): 985-90, 1996. [PUBMED Abstract]
- Pratt LA, Brody DJ: Depression and smoking in the U.S. household population aged 20 and over, 2005-2008. NCHS Data Brief (34): 1-8, 2010. [PUBMED Abstract]
- Orleans CT, Boyd NR, Bingler R, et al.: A self-help intervention for African American smokers: tailoring cancer information service counseling for a special population. Prev Med 27 (5 Pt 2): S61-70, 1998 Sep-Oct. [PUBMED Abstract]
- Audrain J, Boyd NR, Roth J, et al.: Genetic susceptibility testing in smoking-cessation treatment: one-year outcomes of a randomized trial. Addict Behav 22 (6): 741-51, 1997 Nov-Dec. [PUBMED Abstract]