National Cancer Institute NCI Cancer Bulletin: A Trusted Source for Cancer Research News
July 14, 2009 • Volume 6 / Number 14

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Community Update

Oncology Nursing
This is the first article in a new series of stories related to oncology nursing. Look for the symbol on the left in an upcoming issue for the next article in the series.

Making a Difference: Nurses Help Cancer Patients Quit Smoking

One of the most cost-effective ways to improve the care of many patients with cancer is to help smokers stop smoking. Quitting increases a patient’s chances of responding to a particular treatment and it can reduce complications as well as the risk of a recurrence—all of which can save precious health care resources.

While the benefits of quitting smoking after a diagnosis of cancer are clear to researchers, many patients and even health care professionals have not heard this message. That is starting to change. A group of nurse scientists is working to increase awareness among cancer nurses through publications, professional meetings, and Web conferences in some states. At the same time, this group is using new research to develop policies that support their efforts.

“We know that quitting is tough and that patients need support. But just because it’s hard doesn’t mean we shouldn’t try to help these patients.” - Dr. Linda Sarna

As the Oncology Nursing Society (ONS) said in a recent statement on global tobacco use, the leadership and active involvement of nurses will be required to address the worldwide epidemic of smoking-related illnesses.

“Nurses are in a perfect position to do this work,” said Dr. Linda Sarna, a professor at the UCLA School of Nursing and a leader in the field. “We’ve found that a certain percentage of patients continue to smoke after a diagnosis of cancer, and that speaks to the challenges of breaking dependence on tobacco.”

With their knowledge of medications and skills in supporting patients, cancer nurses are uniquely able to help. At all stages of cancer care, from prediagnostic screening to hospital stays and outpatient visits, nurses can identify patients who smoke and assess their willingness to quit. Just as important, studies have shown that when cancer nurses deliver smoking cessation treatments to patients, quit rates rise.

The problem has been that many nurses in cancer care are not aware of the benefits of quitting smoking after the diagnosis of cancer, said Dr. Stella Bialous, president of Tobacco Policy International and a consultant for the World Health Organization. “The biggest challenge has been to make nurses realize that they are incredibly powerful in helping patients with cancer quit smoking.”

“Quitting Is Tough”

Although medications are available to help with the withdrawal symptoms, research suggests that many smokers with cancer are not getting the help they need to quit.

In a recent study of 94 patients with potentially curable lung cancer, only half of the patients who smoked received cessation treatments prior to surgery. And only one patient received the recommended treatment (counseling plus medication). The study also found high rates of smoking relapse in those who were able to quit, including those who had quit more than a year prior to surgery.

Even for patients whose cancers are potentially curable by surgery, quitting can be a challenge, the researchers, led by Dr. Mary Cooley of the Dana-Farber Cancer Institute, concluded. Nonetheless, it is essential for patients to quit smoking in order to improve their survival and quality of life, Dr. Cooley stressed.

“We know that quitting is tough and that patients need support,” commented Dr. Sarna. “But just because it’s hard doesn’t mean we shouldn’t try to help these patients. This is what a good nurse has to do. This must be part of good cancer care.” 

Overcoming Barriers

Like millions of Americans, some nurses also smoke, and researchers believe that this has prevented some nurses from participating fully in efforts to reduce patient tobacco use. To address this problem, Dr. Sarna led the creation of a national program called Tobacco Free Nurses, which includes a Web site dedicated to helping nurses and student nurses stop smoking. The program, funded by the Robert Wood Johnson Foundation, has ended, but the Web site continues to offer resources on tobacco control for all nurses.

Misconceptions among nurses have also hampered efforts, most notably the idea that patients who smoke do not want to quit. In fact, studies suggest just the opposite—patients do want to quit and expect to discuss this with their care providers. For this reason, researchers have encouraged nurses to “not be squeamish” about bringing up the subject.

Another barrier has been lack of training. Most nurses, like most health care professionals, are not trained to help patients quit smoking, leaving some nurses to feel as though they don’t know enough to help patients.

“Once nurses get over the misconception that patients don’t want to quit, the next biggest barrier is the lack of training,” said Dr. Bialous. “We need to get nurses feeling comfortable about doing this work, even if it is just a minimum-level intervention followed by referring patients to a nurse or cessation specialist who can do more, or to the toll-free telephone quitline.” A single nurse with expertise on smoking cessation may serve both patients and nurses in hospital settings as a source for referrals, she added.

Finally, the difficulty of discussing tobacco use near the end of a patient’s life may dissuade some nurses from doing so, particularly when patients blame themselves for smoking-related cancers. But researchers are quick to point out that there are serious safety risks here, too, especially for smokers who use oxygen or are sedated.

Stressful Time

“We have to acknowledge that it is a very stressful time when patients are trying to quit smoking, but all health care providers, and nurses in particular, can tell patients that there are now effective drugs to help them get over some of the symptoms and discomfort associated with withdrawal,” said Dr. Mary Ellen Wewers, a nurse scientist at Ohio State University who has pioneered research in the field. “And in the hospital, the nurse is right there at the bedside and can deliver the behavioral counseling that is so effective,” she added.    

Because smokers tend to live in families that smoke, Dr. Wewers stressed the importance of trying to reach out to the family members of patients. When a family member who smokes brings in a patient for treatment, she noted, it can be an opportunity to discuss smoking cessation with the relative as well.

Important questions about how best to reduce smoking among patients with cancer are still unanswered, including which types of cessation treatments patients prefer and why resources such as online and telephone quitlines are not more widely used. These are questions for future studies.

In the meantime, the leaders of this emerging movement believe there is both momentum and unprecedented interest among nurses. They note that presentations on tobacco control at professional nursing meetings have been packed of late, something that few could have imagined a few years ago.

“This is a very exciting time to be an oncology nurse,” said Dr. Bialous. “We are starting to reach a critical mass at the level of policy making. And among nurses at the staff level, there is both a need and eagerness to learn more and do more.”

—Edward R. Winstead