We know that cigarette smoking is responsible for 30% of cancers in the United States. The article in this volume by Park et al highlights the critical importance of the clinician addressing tobacco cessation, particularly at the time of diagnosis.1 As one would expect, most patients with lung cancer have a history of smoking. Clinicians may be less aware of the data suggesting that there is a causal relationship between smoking and colorectal cancer.2 Greater than 58% of patients with colorectal cancer have a history of smoking, as compared with 42% in the general population. To prevent the 30% of cancers caused by tobacco use, we need to get better at preventing tobacco use initiation and promoting its cessation.
However, this current paper highlights how critical it is for oncologists to address tobacco cessation with their patients—at the time of diagnosis. Most clinicians acknowledge the importance of addressing tobacco cessation in their patients; however, few do it. Most do not know how to do it—they did not receive this education in medical school, nor did they receive focused tobacco use treatment training during residency or fellowship. Few physicians know of the US Tobacco Use Guidelines3 or the tobacco cessation Quitlines that are currently available in all 50 states and many countries.4, 5 Oncologists should follow the protocol of the 2 A's and R: Ask, Advise (ie, give the personalized message that stopping smoking is critical to the patient's cancer treatment and survival), and Refer. The referral should be to an in-house tobacco cessation program or to a state (or national) Quitline. Tobacco use assessment and cessation should be performed by clinicians of all specialties in all patients primarily to prevent cancer, and secondarily to improve response and to prolong survival of patients already diagnosed with a cancer.
Oncologists, however, perhaps need to be particularly focused on tobacco use cessation interventions. Adam Goldstein, MD, MPH surveyed 58 cancer centers throughout the United States (unpublished data) and demonstrated that less than half had a designated tobacco use treatment provider at their center. Thus, it seems that although oncologists know that a substantial proportion of their patients present with a tobacco-caused cancer, a substantial proportion of patients are still smoking at the time of diagnosis. There is much room for improvement for oncologists to more rigorously address tobacco cessation in their patients. In addition, it is critical to understand the risks of relapse; patients may stop smoking shortly before or at the time of diagnosis, but they are at a high risk of relapsing back to smoking during or after their treatment. By asking cancer patients at each visit, a relapse to smoking would be identified and managed, again by advising cessation and referring to an effective cessation program. Tobacco addiction is a relapsing chronic condition and should be managed as such.
The risks of persistent smoking or relapse to smoking are well established for the cancer patient (see numerous other references within the Park et al paper1). If we are to maximize the response to treatment with a consequent improved length and quality of survival, oncologists must address tobacco use in their patients.
Dr. Park and her colleagues as well as others are researching evidence-based methodologies for oncologists to use in addressing tobacco use treatment in the cancer care setting.6, 7 Cessation is possible, particularly with diagnosis-specific interventions. The US Tobacco Use Guidelines recommend the 5 A's—Ask, Advise, Assess, Assist, and Arrange—as the basic outline for helping patients to quit tobacco. The first, Ask, is already frequently performed, but recorded with variable accuracy within the medical record. With upcoming implementation of meaningful use criteria—which will demonstrate that various electronic health data, including tobacco use, are recorded and integrated to improve care delivery—improvement in addressing cessation should occur.8, 9 Oncologists should be able to routinely advise their patients to quit and not relapse— with personalization of the message. No matter the oncologic specialty (surgery, radiation, chemotherapy), data already exist supporting that the most important contribution the patient can make to his or her own treatment is to stop smoking.7, 10
The next steps can be more variable, depending on the resources available at the office, clinic, hospital, or cancer center. At this point, tailoring of the intervention as recommend by Park et al should assist in improving the cessation rate. As the current paper demonstrates, there are differences in demographics and tobacco use patterns depending on the site of the cancer. Future research will determine how critical it is to address these differences and provide methods to do so. However, for the present, we know that physician advice is among the most critical predictors of cessation success. The oncologist can immediately implement the 2 A's and R tobacco use treatment protocol: Ask, Advise (with personalization of the message), and Refer (to the Quitline that is present in all 50 states). It would be even better if the oncologist worked within his or her clinic, hospital, or cancer center to provide more tailored tobacco use treatment interventions on-site. Although all state Quitlines do provide evidence-based interventions, not all Quitlines can afford to provide medication (or sufficient medication), and some may have restrictions on who they are able to help (eg, those without insurance). The US Tobacco Cessation Guidelines recommend US Food and Drug Administration-approved pharmacotherapy in addition to behavioral counseling to maximize cessation success. An on-site cessation intervention program should provide expert knowledge for pharmacotherapy options along with tailored behavioral interventions for the cancer patient.
In particular, the data from Park et al suggest that those patients most likely to relapse seem to be those with the least social support, lower socioeconomic status, and higher rates of depression. We know that these people are increasingly the population that still smokes, as those with higher incomes and higher educational levels tend to have already quit. Just as we need to tailor our cessation interventions prediagnosis, so too must the diagnosis/postdiagnosis cessation interventions be tailored to address a population that perhaps has a more difficult time quitting and not relapsing. In addition, patients at a more advanced stage seem to be less likely to quit—particularly patients with lung cancer. This may be because of oncologists being less willing to recommend cessation interventions on the grounds that they will not make a difference or be too stressful, or so as not to deprive the patient of a last remaining pleasure. All these rationales have previously been heard from colleagues. However, the data are clear—persistent smoking shortens the duration and quality of life that remains.
It is never too late to quit, especially if any treatment intervention is planned. Oncologists must learn how to become effective in helping their patients stop tobacco use. Offices, clinics, hospitals, and cancer centers should have focused programs to help their patients quit. Additional research can help us tailor the message for patients with different types of cancer diagnoses. We know enough now to implement effective cessation programs to identify and help cancer patients quit at the time of diagnosis and support them to prevent relapse. By doing so, we maximize patients' response to therapy, their quality of life, and their longevity.