Very few smoking cessation interventions have been empirically tested with cancer patients. Limited research suggests that many of the factors that influence cessation in cancer patients are similar to those seen in the general population (e.g., nicotine dependence, readiness to quit, age).6 Even though cessation interventions should be tailored to the unique needs of cancer patients (see below), treatment must be informed by evidence from smoking cessation studies in the general population and other patient groups.
Clinical practice guideline
The U.S. Department of Health and Human Services Public Health Service has produced a clinical practice guideline, based on a systematic review and analysis of scientific literature, containing a series of recommendations and strategies to assist healthcare providers in delivering smoking cessation treatment.42 This guideline emphasizes the importance of systematic identification of tobacco users by healthcare workers and of offering at least brief treatment to every patient who uses tobacco. Specific strategies to guide clinicians in providing brief interventions are offered and include: 1) identifying and documenting tobacco use for every patient at every visit, 2) strongly urging every tobacco user to quit, 3) determining the willingness of the tobacco user to make a quit attempt, 4) using counseling and pharmacotherapy to aid patients in quitting, and 5) scheduling follow-up contact. These are referred to as the 5 As (Ask, Advise, Assess, Assist, and Arrange).42
The Clinical Practice Guideline summarizes effective smoking cessation treatments and the benefits of combining treatment modalities.42 Techniques drawn from behaviorally based counseling models—including motivational enhancement,43 problems solving, and skills training—are empirically supported for smoking cessation. Additional counseling components found to be highly effective include the provision of social support and assistance in securing social support outside of treatment. First-line pharmacotherapies for smoking cessation include both nicotine replacement therapy (i.e., nicotine patch, gum, inhaler, spray, and lozenge) and the sustained-release antidepressant bupropion (Zyban, GlaxoSmithKline plc, London, UK), which have been shown to approximately double cessation rates.42
Tailoring of cessation treatment for cancer patients
Unique disease-related issues need to be taken into account when implementing smoking cessation interventions with cancer patients. Smoking-cessation strategies may need to be modified because of physical limitations imposed by disease and treatment. For example, it may be important to offer specially tailored suggestions regarding exercise regimens and dietary change, which are often informal components of smoking cessation programs. Medical contraindications to certain types of nicotine replacement therapy must also be recognized and appropriately managed. Thus, while pharmacological treatment is recommended for all patients as a component of smoking cessation intervention, individuals with oral cancers may be unable to use oral forms of nicotine replacement such as the gum, spray, inhaler, or lozenge. In such cases, the nicotine patch or bupropion may be the most appropriate alternative treatment. It is also important to be sensitive to stressors faced by patients and associated psychological issues and mood disorders such as guilt, depression, and anxiety, all of which may impede smoking cessation efforts. Patients will be particularly sensitive to any perceived blame for their illness, especially when the disease is smoking-related. Instead, the healthcare provider should explain the strong role of nicotine addiction and facilitate motivation for behavioral change using the social support of family, friends, and healthcare professionals. In a sample of lung cancer patients, Walker et. al.13 provided some noteworthy preliminary findings on how patients' “reactance”, or receptivity to advice and direction, may serve as a guide to offering directive advice and support. For example, patients who are more adherent, in general, may benefit from more directive advice and support, whereas more resistant and nonadherent patients may do better with less directive advice and support. This is certainly an area for additional research.
As quit rates have been reported to be higher for patients with cancers strongly related to smoking,6, 7 it is likely that awareness of the connection between diagnosis and smoking status facilitates smoking cessation. Healthcare providers play a crucial role in underscoring this link. Education on the health risks of continuing to smoke after diagnosis, regardless of cancer type, and the health benefits of smoking cessation may be particularly useful in increasing motivation and interest in quitting.
Helping patients to sustain smoking cessation poses another unique challenge in working with cancer patients. Although relapses in healthy persons usually occur within the first week after cessation, relapses in cancer patients are often delayed because of surgical and other posttreatment healing. Gritz, et al. reported that among head and neck cancer patients who relapsed to smoking after quitting successfully, the majority of relapses did not occur until 1–6 months after surgery.44 This delay in relapse may signal a waning motivation for abstinence as patients recover physically and return to their prediagnosis lifestyle. Thus, interventions to prevent relapse and promote sustained abstinence are particularly important as patients heal.
Empirically tested cessation interventions with cancer patients
Several studies examining the efficacy of smoking cessation interventions designed specifically for cancer patients were conducted within hospital settings and delivered by nurses. The typical intervention used in these studies consisted of three in-hospital visits, the provision of educational materials, and five postdischarge telephone calls. Findings indicated higher abstinence rates in the intervention group than in the usual-care control group; however, these rates varied greatly from study to study. Across two studies, abstinence rates at the time of the first postdischarge visit varied between 65–75% for the intervention group compared with 43–50% for the control group.45, 46 Wewers and colleagues47 reported abstinence rates of 40% at 6-week follow-up for lung cancer patients using this same intervention in a single group design. In the most recent study conducted with cancer patients by these investigators, the abstinence rate in the intervention group was only 21%, compared with 14% in the usual-care condition at 6 weeks postintervention.48 However, a more modest treatment was used with only one in-hospital nurse visit, provision of educational materials, and five postdischarge telephone calls. It was concluded that a more intensive intervention might be needed.
A randomized, controlled trial of a surgeon–dentist-delivered intervention for patients with primary squamous cell carcinoma of the upper aerodigestive tract was conducted by Gritz and colleagues.6, 10, 36 In this study, both intervention- and control-group patients received personalized risk factor information and strong advice to quit smoking from their surgeon or maxillofacial prosthodontist. Although the intervention group's quit rates were not significantly increased by the addition of signed quitting contracts, tailored booklets, reminder postcards, and booster sessions at follow-up medical visits, the high quit rates for all participants (70.2% continuous abstinence at 1-year follow-up) suggests that brief advice, given in the context of medical care, is a powerful tool. In another study of physician-delivered advice, the potential need for more intensive treatment for some cancer patients was demonstrated by Schnoll and colleagues.49 In this study, cancer patients with various diagnoses were randomly assigned to usual care with unstructured smoking-cessation advice or a physician-delivered smoking intervention based on National Institutes of Health guidelines. No differences in cessation rates were found between the groups at the 6- or 12-month follow-up, ranging from 12% to 14%. The higher quit rates found by Gritz and colleagues are likely explained by the targeting of patients with a smoking-related cancer (i.e., head and neck cancer) by their direct treatment providers.
Additional studies have compared outcomes between cancer patients and other participants in general smoking cessation programs conducted at the Mayo Clinic Nicotine Dependence Center, which offered a range of treatments over time. A matched-pair design was used to retrospectively analyze abstinence rates at 6-month follow-up for patients with certain types of cancer compared with the general patient population. Sanderson Cox and colleagues50 reported that lung cancer patients were significantly more likely to achieve 6-month tobacco abstinence than controls (other cancer patients and noncancer patients), 22% versus 14%. However, in another Mayo Clinic study, Garces et al.51 found no significant differences in abstinence rates between head and neck cancer patients (33%) and controls (26%). Both studies found that duration of time between cancer diagnosis and smoking cessation treatment significantly affected tobacco use outcome. Significantly higher abstinence rates were found for both lung and head and neck cancer patients treated within 3 months of diagnosis compared with those treated more than 3 months after diagnosis, emphasizing the importance of early treatment after diagnosis.
Case histories: the need for intensive smoking cessation interventions for cancer patients
Cancer patients who continue to smoke after physician-delivered advice or other brief cessation interventions are likely to require intensive interventions that combine multiple treatment modalities. The first three cases of the five presented below illustrate the detrimental effects of continued smoking on cancer treatment outcomes and difficulties that cancer patients face in quitting smoking and remaining abstinent.
This 52-year-old woman was diagnosed with a Stage II infiltrating ductal carcinoma of her right breast. At the time of diagnosis, the patient was divorced with no known psychiatric history. She endorsed rare alcohol use and no drug use. She had a history of chronic obstructive pulmonary disease (COPD), intermittent bronchitis, and pneumonia. She started smoking at age 16 years, and other than stopping for about 4 years many years ago, she smoked between 1 and 2.5 packs per day until diagnosis. Between diagnosis and treatment, her smoking decreased to one cigarette per day, and she was noted to be taking bupropion to assist with smoking cessation.
The patient underwent a right modified radical mastectomy, followed by chemotherapy and radiation therapy. Later, she developed recurrent upper respiratory infections and pneumonia. She indicated that she was smoking about a half pack of cigarettes per day. After repeated attempts at quitting with subsequent relapse, the patient enrolled in a smoking cessation clinic. She was treated with behavioral counseling, nicotine patches, and bupropion. She reportedly remained abstinent for 5 months, and then she underwent a delayed right breast reconstruction with a TRAM pedicle flap. Her postoperative course was complicated by fat necrosis in the right breast and in some of the skin at the TRAM donor site. The patient admitted that she resumed smoking (1–2 cigarettes per day) upon discharge from the hospital. The patient was repeatedly advised by her surgeon that continued smoking would have a deleterious effect on her healing and prolong her recovery. The patient continued to intermittently endorse and deny occasional smoking.
She then underwent debridement of the tissue at the abdominal donor site and the part of the TRAM flap comprising the upper half of her right breast. Later, the abdominal donor site was closed with a skin graft. The patient was informed that complete smoking cessation was required before any surgery could be performed to complete the reconstruction of her right breast and revise the donor site scar. She was referred to a smoking cessation clinic where she received counseling and bupropion treatment. Approximately 10 months after the skin graft procedure, she stated that she had remained abstinent from smoking for several weeks. To verify her compliance with smoking cessation, a urine specimen was obtained; the urine cotinine was negative for nicotine use.
She underwent a revision of her right breast with a latissimus dorsi myocutaneous flap and revision of the TRAM donor site. A left prophylactic mastectomy was performed at the same time as this procedure. A urine cotinine level was obtained during the surgical procedure and was positive for nicotine use postoperatively. The patient continued to deny smoking. She suffered wound healing problems involving skin edge necrosis on the back, which eventually resolved. The patient underwent the next stage of reconstructive surgery about 4 months later. She tolerated this surgery well and had no smoking-related complications.
This 44-year-old married woman was diagnosed with a large squamous cell carcinoma of the left cheek. The patient admitted to smoking approximately a half pack of cigarettes a day for the last 21 years. She denied alcohol or illicit drug use. The tumor was widely excised, and the resulting large cheek defect was closed with a large local skin flap. At discharge, the flap was noted to be viable; however by the 10th postoperative day, the distal one-third of the flap had become necrotic. Although the patient had reported discontinuing tobacco use before surgery, she resumed smoking soon after discharge.
The necrotic cheek skin was surgically debrided, and the wound closed with a full-thickness skin graft. The skin graft survived transplantation, but the thinness of the graft resulted in a significant contour deformity. Unfortunately, the patient became significantly depressed because of facial disfigurement, an outcome that she ascribed to the reconstructive surgeon. The patient further reported increasing marital discord about her physical appearance and the lack of family support for smoking cessation. She requested a second opinion to remove the skin graft and correct the deformity. Another plastic surgeon evaluated the patient and felt that that surgical correction was possible if the patient could quit smoking and her depression was adequately treated. The patient was referred to the psychiatry service and smoking cessation clinic, and additional surgery to correct the deformity was postponed until she could abstain from smoking for at least 1 month before the surgical intervention.
In smoking cessation clinic, the patient reported continuing to smoke approximately 3–4 cigarettes per day. She was initially prescribed bupropion and a 7 mg starting dose of nicotine replacement patches. She was educated about components of nicotine addiction, learned problem-solving techniques, and was scheduled for additional counseling sessions. The patient subsequently elected to start a 21 mg dose of nicotine replacement that had been previously made available to her. This led to alterations in her treatment course, as extended time was needed to gradually reduce the nicotine levels in the patches. She attended only one follow-up session in the smoking cessation clinic.
Two months later, the patient stated that she had abstained from smoking and using nicotine patches for 3 continuous weeks. Several weeks later, she underwent subcutaneous placement of tissue expanders on the left side of her face, neck, and upper chest wall region. However, the patient's preoperative cotinine level was later found to be positive for nicotine, indicating she had either continued to smoke or was using nicotine replacement treatment before surgery. During the next clinic visit, the test results were presented to the patient, but she continued to deny smoking and refused to provide a urine specimen for a cotinine level to verify compliance with smoking cessation. The following week, she willingly provided a urine sample; however, she became tearful and confessed that she had been smoking about four cigarettes a day when asked to also provide a saliva sample for a cotinine level during the same visit. The patient obtained a psychiatric evaluation. She endorsed symptoms of chronic low mood for the past 2–3 years, low self-esteem, and significant feelings of guilt about continuing to smoke. She was diagnosed with dysthymia with anxious features, prescribed antidepressant medication, and subsequently engaged in individual therapy sessions.
Ultimately, infection led to exposure of the tissue expanders, and they had to be removed. The neck skin was advanced without tension to remove some of the skin graft. Postoperatively, the patient continued to smoke cigarettes despite the surgeon's warnings of continued difficulty with wound healing. The last known clinical contact that addressed the patient's smoking status indicated that she had not yet abstained from smoking. Moreover, her spouse was not supportive of her efforts at smoking cessation and continued to smoke in front of her.
Discussion of cases.
In the two cases presented above, the harmful impact of nicotine addiction was manifested in delayed and failed reconstructive procedures at psychologically sensitive and value-laden body sites—the breast and the face. Although surgical complications related to skin and fat necrosis cannot be entirely eliminated with smoking cessation, continued smoking undoubtedly increases the risks of such adverse effects.18, 52 Both patients had long histories of moderate to heavy smoking and alleged periods of intermittent smoking reduction or abstinence. Treatment for nicotine dependence in these patients was complicated by repeated relapses to smoking (Case 1), depressive symptoms and seemingly inadequate social support (Case 2). In both cases, physicians took an active role in promoting smoking cessation, advised on the risks of continued smoking, and delayed nonessential surgical procedures until smoking cessation could be achieved. Unfortunately, in Case 2, the patient was unable to be truthful about her continued smoking. The surgeon requested biologic samples for confirmation of abstinence on repeated visits to provide the optimal medical care. This led to a psychiatric referral and appropriate evaluation and treatment for the patient's mood disorder.
In cases such as these, simultaneous, multiple approaches may be necessary. Consultation with smoking cessation specialists is vital for these patients. Treatment strategies should be guided by a thorough assessment of tobacco use, which includes examining current level of motivation to quit and remain abstinent. It is recommended that smoking behaviors continue to be evaluated (and biochemically verified) by the treating physician at each follow-up visit. For patients such as the woman described in Case 1, particular emphasis should be given to providing an intervention that focuses on relapse prevention. In addition to counseling and behavioral strategies to promote relapse prevention, it is recommended that smoking behaviors continue to be evaluated by the treating physician at each follow-up visit. This will allow patients to discuss any difficulties with quitting (e.g., craving, withdrawal symptoms, depression, medication side effects, and high-risk situations for relapse) and facilitate prompt encouragement and support for resuming cessation in the event of a relapse to smoking.
In both cases described above, higher doses of nicotine replacement therapy over longer treatment periods, concomitant with pharmacologic treatment of depression, should be considered. For patients such as the woman described in Case 2, thorough assessment and treatment of depression and other mood disorders is likely to be critical to successful treatment. Moreover, Case 2 highlights the importance of attending to and understanding the patient's existing social network. Behavioral strategies to improve social skills and facilitate effective communication with spouses, family members, or other significant figures in the patient's life are recommended. Systemic interventions to actively involve family members should also be considered. In this way, the patient can be made a full partner in the therapeutic alliance against nicotine addiction, not its failed victim.
This 64-year-old man was diagnosed with a large squamous cell carcinoma of the larynx. Before diagnosis, the patient had smoked 3 packs per day for 40 years. The patient is married and has no known psychiatric history or history of illicit substance or alcohol abuse. The patient reported that he reduced his cigarette consumption to a half pack per day after diagnosis. He was initially treated with chemotherapy and radiation. At the advice of his healthcare provider, the patient engaged in smoking cessation treatment, which consisted of behavioral and pharmacologic interventions. He subsequently relapsed to smoking and did not return for additional counseling sessions.
Within 1 year, the patient was diagnosed with an adenocarcinoma of the lower right lobe of the lung. Surgery was delayed until the patient could abstain from smoking to minimize his chances of perioperative pneumonia. Approximately 1 month later, the patient underwent a right lower lobectomy with mediastinal lymph node dissection to remove the tumor. He resumed smoking after surgery, and approximately 3 months later was noted to have chronic nicotine and reflux changes to his larynx. The patient had intermittent contact with a smoking cessation counselor, but he was noted to continue smoking approximately a half pack per day.
One year later the patient reported persistent cough, frontal headaches, and chronic postthoracotomy pain. He subsequently enrolled in a Southwest Oncology Group (S0002) smoking cessation trial during which he received: behavioral advice delivered by healthcare providers; pharmacotherapy including the use of nicotine replacement patches and randomization to bupropion or placebo; targeted written materials (Public Health Service-based tip sheets, etc.); and 5 follow-up telephone calls to reinforce the intervention over a 10-week interval. This patient was not randomized to the arm of treatment that included bupropion (i.e., he received placebo.). With this intervention, the patient effectively established a quit date and abstained from smoking for 3 weeks. After the onset of general feelings of ill health and the development of an upper respiratory tract infection, the patient stopped adhering to smoking cessation treatment and relapsed to smoking. He was unable to set another quit date and eventually declined to continue participating in the intervention. The patient continued to smoke approximately a half pack of cigarettes per day. His chest film and computed tomography (CT) scan showed changes consistent with emphysema. During the following year, repeat CT and positron emission tomography (PET) scans showed prominent, but stable, paratracheal lymph nodes. The patient is scheduled for annual follow-up evaluations to monitor the status of these nodes. He continued to smoke approximately 1 pack per day as of the last clinical contact.
Discussion of case.
For patients such as the man described in Case 3—a seriously ill patient with a long-term history of heavy smoking and only limited periods of smoking reduction and abstinence—the presence of multiple primary cancers, comorbid disease, and deteriorating health may all contribute to declining motivation to maintain abstinence and seek further smoking cessation treatment. In such cases, the complications and symptoms of advanced disease may be mitigated by eliminating smoking. The 10-week intervention in which this patient participated was not sufficient to promote long-term smoking cessation. Although the optimal length of intervention may vary, prolonged pharmacologic treatment with both nicotine replacement and an antidepressant as well as sustained guidance from healthcare providers regarding problem-solving and skills training are indicated. Psychological issues including guilt, depression, anxiety, and stress should also be considered and managed appropriately. Intensive psychological support, including a family conference, may be helpful, because such patients may also benefit from involvement of spouses and other important members of their social network in their treatment. It is particularly important to assess whether these patients live with individuals who smoke, as this can represent a significant barrier to smoking cessation (as in Case 2).
Examples of successful smoking cessation treatment
In the final two clinical cases, the healthcare provider's active role in promoting smoking cessation led to positive outcomes.
This 54-year-old woman was diagnosed with ductal carcinoma in situ in both breasts. She is married, with no alcohol or drug use and no known psychiatric history. She had a history of smoking at least a half pack per day, but she had quit for the past 7 years. One month before her diagnosis, the patient resumed smoking 5–6 cigarettes daily. Subsequently, she underwent wide excision of the left breast tumor and segmental mastectomy of the right breast. Although the margins of resection were negative for tumor in the left breast, residual disease was found at the deep margin of the right breast.
Because she had carcinoma in situ in both breasts and a significant family history of breast cancer, she was advised to undergo a modified radical mastectomy and immediate reconstruction of both breasts. During the consultation with the plastic surgeon, she admitted to continued smoking. The patient was considered to be an appropriate candidate for a TRAM free flap breast reconstruction provided she stopped smoking as soon as possible and remained abstinent before and after surgery. The plastic surgeon fully discussed the increased risks for necrosis of the breast skin, the skin and fat of the TRAM flap, and its donor site because of inadequate perfusion of blood through these tissues if she continued to smoke. The patient reportedly took the advice of the surgeon and stopped smoking.
Approximately 3 weeks later, she underwent a skin-sparing mastectomy and immediate reconstruction of both breasts with a TRAM free flap. Six months after surgery, the patient was evaluated for the next stage of breast reconstruction, involving a revision of the reconstructed breasts and bilateral nipple reconstruction. From the initial consulting visit with the plastic surgeon through all stages of breast reconstruction, the patient remained abstinent from smoking and did not suffer a major complication.
This 63-year-old woman presented with a squamous cell carcinoma of the floor-of-mouth and was evaluated for possible reconstruction after tumor resection. She is married, does not drink alcohol, and has no history of psychiatric disorder. The patient had smoked 1.5 packs of cigarettes a day for 40 years and had never attempted to quit. She was seen by a smoking cessation specialist and started on buspirone, an antianxiety agent that has been used with some success in smoking cessation treatment. The patient was informed that she must stop smoking, preferably the day of the consultation. She was seen again 1 and 2 weeks later; she had markedly decreased her smoking to 2 cigarettes a day, but she did not totally quit until her surgery.
The patient underwent composite tumor resection and immediate reconstruction of the missing mandible, floor-of-mouth, and part of the oral tongue with a fibula osteocutaneous free flap. The patient's hospital course was without problems. On the 6th postoperative week, she began radiation therapy and experienced no significant complications during recovery. The smoking cessation specialist contacted her family by telephone 3 months after surgery and learned that she was not requesting nor discussing smoking again. She has been able to abstain from tobacco and nicotine use for 5.5 years.
The patient developed lung cancer 3.5 years after her head and neck diagnosis. She was treated by resection of the upper lobe of the right lung, along with three ribs and the transverse processes of the 3rd and 4th vertebrae. However, she recuperated successfully from this treatment and is alive and free of disease.
Discussion of cases
The two successful smoking cessation cases illustrate several salient points. Patients who are lighter smokers, have a long history of past successful quitting, and a relatively short relapse period (Case 4) are excellent candidates for resuming abstinence. Their self-esteem regarding quitting is likely high, and they can draw upon past experience to deal with temptation, count upon family support, as well as benefit from the strong and targeted advice of the treating physician. In the example of a heavy smoker with no history of cessation (Case 5), the astute evaluation by a smoking cessation specialist with the prescription of appropriate pharmacotherapy and follow-up sufficed to support a successful quit effort. Interestingly, although this patient developed a second primary tumor, she was curatively treated for it, maintained abstinence from cigarettes, and has not suffered further disease. It is very possible that her successful abstinence has contributed to her long-term recovery.