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Provide an overview of the impact of smoking after a diagnosis of lung cancer, discuss the relationship between smoking cessation and improved outcomes during the lung cancer trajectory, present information about tobacco dependence evidence-based treatments, reimbursement for these treatments, and tobacco-related resources available for patients and health care professionals, and emphasize the important role of nurses.
Published articles, reports, websites, and research studies.
Tobacco use is associated with 30% of cancer deaths. Prevention of tobacco use and cessation are primary ways to prevent lung cancer. However, even after a diagnosis of lung cancer, smoking cessation is important in improving survival and quality of life. Although effective tobacco dependence treatments are available to help smokers quit smoking, persistent efforts over repeated contacts may be necessary to achieve long-term cessation.
Oncology nursing action is essential in the identification of and intervention with patients who struggle with tobacco dependence after diagnosis.
Lung cancer is one of the most common smoking-related malignancies accounting for the second most common cancer, and the leading cause of cancer death in men and women in the United States (US). Lung cancer causes more deaths than the next three most common cancers (breast, colorectal and prostate) combined. An estimated 160, 390 deaths will occur from lung cancer during 2007. It is estimated that 90% of lung cancers are related to smoking. 1
Although the link between smoking and lung cancer is well-established, the benefits of smoking cessation after a diagnosis of lung cancer are not as widely recognized. Smoking cessation can improve survival, treatment efficacy, and improve overall quality of life 2–4. Approximately half of all smokers have quit prior to their diagnosis 5. Despite a diagnosis of cancer, the addictive properties of nicotine can make quitting difficult and the risk for relapse high. This article provides an overview of the impact of continued smoking after a diagnosis of lung cancer and the importance of smoking cessation. The benefits of quitting, and the important role of the oncology nurse in assisting these efforts, will be emphasized along with strategies to incorporate smoking cessation interventions into the clinical setting.
The prevalence of smoking among newly diagnosed lung cancer patients tends to be higher than the general population. Estimates for the prevalence of smoking have ranged from 24% to 60% among newly diagnosed lung cancer patients as compared to 12% to 29% among the general United States population 5–7. Although the diagnosis of lung cancer presents a compelling reason to quit smoking, studies have estimated that between 8% to 17% of smokers continue to smoke after the diagnosis 5,6. This finding underscores the highly addictive nature of tobacco dependence and the importance of assessing smoking status at diagnosis and incorporating smoking cessation interventions into clinical care.
Smoking cessation has immediate as well as long-term benefits. The immediate benefits of smoking cessation are lower blood pressure, improved oxygen transportation, improvements in smell, taste, circulation and breathing, increased energy, and a heightened immune response 8. Quitting smoking is associated with improvements in cognitive function, psychological well-being and self-esteem leading to an overall improvement in quality of life 9. Lung cancer patients who stop smoking experience similar health benefits. For instance, lung cancer patients who stopped smoking reported decreased fatigue, shortness of breath, increased activity level, and improved appetite, sleep, and mood4.
Smoking can negatively affect outcomes of cancer treatments through direct and indirect effects. Tobacco smoke and its constituents have active biological effects that can interact with cancer treatments. Moreover, the type and severity of smoking-related comorbidities may affect the type of cancer treatments that are chosen. For example, severe lung or cardiovascular disease may limit the option for or extent of lung cancer surgery, use of radiation treatment or type of chemotherapy agent that can be used in treatment. An overview of the impact of smoking on cancer treatment modalities and their outcomes are provided in the following section.
Smoking can adversely affect outcomes for those undergoing lung cancer surgeries, even in the absence of chronic lung disease. Smokers’ are at increased risk of experiencing post-operative complications, such as delayed wound healing, and pulmonary and cardiovascular complications, as compared to non-smokers or former smokers 10. However, outcomes may improve with smoking cessation prior to surgery. Controversy exists about the best time to quit smoking 11,12. Current evidence suggests that it is safe and important to quit smoking as soon as possible prior to lung cancer surgery 12.
Smoking increases complications of radiation therapy and can adversely affect outcomes. Smoking history was found to be a major risk factor for development of radiation pneumonitis after treatment for lung cancer. Patients who continue to smoke and undergo radiation therapy have a 20% greater probability of experiencing radiation pneumonitis 13. Also, infection rates were higher among lung cancer patients receiving radiation treatment who had higher pack-years of smoking, which was associated with decreased survival 14.
Continued smoking can have detrimental effects on efficacy of chemotherapy for lung cancer patients. Multiple mechanisms including chemoresistance, chemo-insensitivity and altered chemotherapeutic levels may partially explain this phenomenon. There is evidence that nicotine increases the metabolism of multiple drugs via the induction of hepatic enzymes, potentially decreasing efficacy of certain agents 15. Another mechanism to explain poorer clinical outcomes is that although nicotine is not carcinogenic, it can induce cell proliferation and angiogenesis and suppress apoptosis induced by certain chemotherapeutic agents. A recent study has demonstrated in vivo that nicotine inhibited the apoptotic potential of cisplatin, a common agent used to treat lung cancer 16.
Smokers in smoke-free hospital and hospice settings may experience severe nicotine withdrawal symptoms such as irritability, anxiety, insomnia, depressed mood, and restlessness. In fact, case reports have described delirium and terminal restlessness to be manifestations of nicotine withdrawal17. Smokers who enter end of life and continue to smoke can pose safety hazards to themselves and others. Continued smoking and changes in mental status can create a risk for starting a fire. Thus, assessment of smoking status is essential throughout the continuum of care so that appropriate tobacco treatment interventions can be initiated.
In 1988, the Surgeon General’s Report on Nicotine Addiction provided conclusive evidence that tobacco is addicting in the same way as other drugs that are responsible for addiction. In fact, nicotine, the dependence producing substance in tobacco, is similar to heroin and cocaine in its addictive properties18. This landmark report promoted the fact that tobacco dependence is a chronic condition characterized by periods of abstinence and relapse, thus requiring repeated interventions by clinicians. Tobacco dependence is a complex process that is characterized by physical, psychological, social, and behavioral components, which must all be addressed to enhance success of treatment.
Oncology nurses are in a unique position to assist their patients to quit smoking during a time when patients are motivated and willing to quit. The Treating Tobacco Dependence Clinical Practice Guideline (Guideline) for treating tobacco dependence is available through the US Public Health Service8. This version is being revised and a new edition will be available in the future. The current Guideline recommends use of the five A’s model (ask, advise, assess, assist, and arrange) to guide treatment (Table 1). The five R model (relevance, risks, rewards, roadblocks, repetition) with strategies to enhance motivation for smoker’s with difficulty quitting is displayed in Table 2. In addition, tobacco dependence treatment (TDT) is significantly enhanced with the use of pharmacological cessation aides and behavioral counseling. Lung cancer patients who continue smoking after diagnosis are often highly dependent smokers. Thus, the following section provides an overview of TDT with an emphasis on treatment of highly dependent smokers.
The use of pharmacological cessation aides has been found to double long-term smoking cessation rates 8. First-line TDT includes: nicotine replacement therapies (NRT’s), buproprion, and varenicline 19. Combined pharmacological treatment increases abstinence rates and should be considered for patients who have failed previous single modality treatments 8. Two other medications are recommended by the US Public Health Service as second line TDT: clonidine and nortriptyline 8. These drugs have evidence for efficacy in TDT but play a limited role due to lack of Federal Drug Administration approval and potential for side effects. These agents may be used if patients do not respond to first line treatments. Because smoking cessation is difficult, especially for highly dependent smokers, relapse back to smoking can be framed as an opportunity to try different medications, higher dosages, or treatment combinations rather than as a treatment failure. The choice of medications is usually selected based on patient preference, insurance coverage, drug cost, and previous experience with cessation aides 19.
Five forms of NRT are available in the US; patch, gum, nasal spray, inhaler, and lozenge. Table 3 provides an overview of dosing, prescribing and precautions associated with each form of NRT available in the US. NRT works by partially replacing nicotine levels thereby reducing nicotine withdrawal symptoms. One major problem with the efficacy of NRT’s is that they do not deliver nicotine nearly as fast or efficiently as cigarettes. Two other problems undermining efficacy of the patch are underdosing, especially among heavy smokers, and that there is not a way to manipulate nicotine levels during urges 19,20. In order to address inadequate replacement with the standard 21 mg patch dose, higher doses of NRT have been tested in clinical trials. A meta-analysis of the efficacy of NRT concluded that there is a small benefit gained from using higher doses of NRT but further studies are needed to reach more definitive conclusions 21. In order to address the shortcomings of manipulating nicotine levels during urges, there are now multiple forms of short-acting NRT’s. One drawback of using short-acting NRT’s alone is that they require frequent administration (every 1–2 hours). However, they can be combined with the patch to enhance efficacy. Meta-analysis of combined NRT versus single NRT have shown combined treatment is more effective 8.
The availability of multiple routes of administration provides an opportunity to combine delivery systems or to individually tailor TDT. Combining the patch with a fast-acting NRT provides a way to titrate nicotine according to a smoker’s needs. Comparisons among the various NRT delivery systems have not shown any clear advantages. Therefore, patient preference is an important consideration when choosing the most appropriate agent for an individual. Several studies assessing patient preference for different forms of short acting NRT have identified the inhaler or the spray to be the preferred method of administration, especially among heavier smokers 20,22.
The tailored use of NRT within subgroups of smokers may increase efficacy of treatment. Lerman and colleagues found that low to moderate smokers, white and non-obese benefited more from the patch, whereas smokers who were highly dependent, obese or members of an ethnic minority group benefited more from nasal spray 22. Pre-testing various short-acting NRT’s prior to their use has been suggested as a strategy to enhance adherence and efficacy of the treatment 20. Pharmacogenetic approaches to individualizing TDT are underway and appear to be a promising direction for future treatment. Readers are referred to additional sources for this information 23.
Buproprion is an atypical anti-depressant that works by inhibiting the reuptake of dopamine and norepinephrine. Studies have demonstrated that buproprion demonstrated higher quit rates as compared with the patch. Buproprion may be combined with the patch but abstinence rates achieved from combined treatment are not higher than using buproprion alone 8. However, a recent study showed that buproprion combined with nasal spray had superior outcomes as compared to either drug alone 24. It has also been shown to be more effective in certain subgroups of smokers, such as those who are more prone to relapse, females (especially those who smoke <10 cigarettes per day), blacks and those with higher dependency. In addition, it can reduce cancer-related fatigue, depression and abstinence induced negative mood especially among highly dependent smokers 19,25. Thus, this agent may be a good choice for lung cancer patients who are also experiencing depression.
Varenicline is the newest pharmacological cessation aide approved in 2006. This drug works by attenuating nicotine’s effect on dopamine release, while maintaining dopaminergic tone. It is a selective alpha 4, beta 2, neuronal nicotinic achetylcholine receptor partial agonist. It exhibits both agonist and antagonist function, which inhibit craving and withdrawal while attenuating the reinforcing effects of nicotine. In clinical trials, varenicline achieved quit rates four times higher than placebo and double the rate of bupropion 26. Currently, there are no data available about the use of varenicline and tobacco cessation outcomes among patients with cancer. However, since nausea is a potential side effect of varencline, it may not be the most appropriate agent for those undergoing active cancer treatment, such as cisplatin, that may also have this side effect.
Behavioral counseling programs are a necessary part of TDT programs because pharmacological cessation aides and behavioral counseling each independently increase cessation rates. Skills training that includes: social support, counseling about cognitive and behavioral ways to cope with smoking urges and general information about tobacco dependence are used to enhance pharmacotherapy. Most patients with lung cancer who smoke have tried to quit smoking before their diagnosis and assessment of reasons for relapse will be helpful in providing additional counseling. Higher quit rates are achieved with increasing intensity of behavioral counseling. Four to seven person to person contact sessions during a period of at least 8 weeks, with counseling sessions lasting at least 10 minutes are optimal for enhancing smoking cessation rates8.
To date, there are few randomized clinical trials examining behavioral treatments in combination with TDT for lung cancer patients 27. For highly dependent smokers, the use of tailored intensive interventions may be beneficial. This type of approach combines behavioral interventions with pharmacological cessation aides and focuses the intervention on specific needs of the subgroup of smokers. One of the problems with intensive interventions, however, is that not all patients may be interested or able to participate in this approach. Thus, other innovative interventions need to be examined. The use of telephone counseling has been shown to be effective among the general population 28. Telephone counseling is now available in every state through out the United States (1–800-Quit Now). Evidence has shown that proactive counseling helps motivated smokers stay abstinent and that three or more calls increase the odds of quitting as compared to standard self-help or brief health care provider advice.
Nurses can make an enormous difference in tobacco control. If each of the 2.2 million nurses working in the US helped one smoker quit per year, they would triple the US quit rate29. In order to make this happen, routine assessment and treatment of tobacco must be integrated into clinical practice. Recent advances in providing reimbursement for TDT provide further incentive for integration of these services into clinical practice. Medicare and Medicaid coverage is now available for intermediate and intensive TDT counseling. In addition, the percentage of insurers providing full coverage for pharmacological cessation aides has more than tripled from 1997 to 2002 30. Potential barriers for incorporating TDT into practice are the lack of knowledge about TDT interventions in cancer patients, lack of training, and continued smoking among nurses. Patient-related barriers, such as perceived stigma associated with a smoking-related cancer and continued smoking among family members, may also play a role in preventing effective delivery of cessation interventions.
Wewers and colleagues conducted a series of small studies in lung cancer patients 31–33. The collective results from these studies suggest that nurse delivered TDT interventions improve cessation rates. Further studies are needed to test interventions specifically designed for lung cancer patients. In the meantime, intervention components from the general population are readily applicable to lung cancer patients.
Adequate training in providing TDT is essential for nurses to be able to successfully incorporate these interventions into their practice. Although, Wewers and colleagues34 found limited coverage of TDT in their survey of nursing programs, new resources are now available for practicing nurses (see Table 4). Several years ago, Sarna et al 35 identified that although most oncology nurses encounter smokers in their practice, only 10% had heard of the Guideline for TDT. The majority of nurses wanted to help patients quit smoking but needed further training. This study also found that, similar to other health care professionals, nurses who smoke were less likely to intervene with patients. These findings underscore the importance of integrating education about TDT into nursing schools, providing continuing education about tobacco cessation within practice settings, and supporting smoking cessation programs for health care professionals. The Tobacco Free Nurses (www.tobaccofreenurses.org) initiative provides resources for nurses to use in helping patients quit as well as support for nurses and student nurses who want to quit smoking.
Some health care providers may expect that the diagnosis of cancer alone will provide enough motivation for patients to quit smoking. It is essential to understand the highly addictive nature of tobacco dependence and the fact that some patients will require repeated TDT over time to be successful in their cessation efforts. Thus, nurses must approach TDT in lung cancer patients with sensitivity. Patients may be embarrassed and not willing to disclose their smoking status because of the stigma that is associated with a smoking related malignancy. Sharing information with patients that quitting smoking may be difficult but assuring them of the benefits and that effective TDT are available may enhance their comfort.
The time surrounding a diagnosis of cancer may enhance family members’ willingness to quit smoking. Thus, assessment of family smoking and offering clinical interventions to other family members may also enhance patient success with quitting and potentially improve the health of family members by preventing tobacco related comorbidities.
Smoking cessation after the diagnosis of lung cancer is essential to improve clinical outcomes. Although effective TDT are available to help smokers quit smoking, persistent efforts over repeated contacts may be necessary to achieve long-term cessation. Oncology nurses have the potential to make an enormous difference in the successful integration of tobacco dependence services into clinical settings. Further knowledge and training in TDT is needed to make this a reality.
This work was supported in part by grants from the National Cancer Institute (Grant #1K07 CA92692, Mary E. Cooley, PI)
This work was completed from the Phyllis F. Cantor Center, Research in Nursing and Patient Care Services, Dana Farber Cancer Institute, Boston, MA; Yale Comprehensive Cancer Center and Yale School of Nursing, New Haven, CT; and University of California, Los Angeles, School of Nursing, Los Angeles, CA.
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Mary E. Cooley, Nurse Scientist, Phyllis F. Cantor Center, Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA.
Rebecca L. Sipples, Thoracic Oncology Nurse Practitioner, Yale Comprehensive Cancer Center, Yale University School of Nursing, New Haven, CT.
Meagan Murphy, Research Intern, Phyllis F. Cantor Center, Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA.
Linda Sarna, Professor, University of California, Los Angeles, School of Nursing, Los Angeles, CA.