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The National Cancer Institute cancer centers possess the credibility to help smokers quit. With the greater life expectancies forecast for patients with cancer, addressing smoking at cancer centers has taken on greater importance.
Despite prevention efforts, changes in social policy, and the advent of effective medications for tobacco dependence, 21% of the US population currently smokes. Further, upward of 50% of patients with cancer who were smokers before their diagnosis continue to smoke, and, even for patients who are able to quit after their diagnosis, relapse rates are substantial. Tobacco use is the leading cause of preventable death in the United States, and continued smoking by patients with cancer can reduce medical treatment effectiveness and diminish quality of life.
The National Cancer Institute (NCI) cancer centers represent nodal points to treat tobacco dependence. NCI cancer centers possess the credibility to help smokers quit, and with the greater life expectancies forecast for patients with cancer, addressing smoking at cancer centers has taken on greater importance. Consequently, in December 2009, the NCI Tobacco Control Research Branch and the Office of Cancer Survivorship sponsored a 1-day meeting at the National Institutes of Health on treating tobacco dependence at NCI cancer centers. This meeting (1) highlighted the importance of treating tobacco dependence in the context of cancer care and survivorship, (2) reviewed guidelines for treating tobacco dependence in the context of cancer care and survivorship, (3) discussed models for tobacco dependence treatment in the oncologic context, (4) discussed barriers to the implementation of tobacco dependence treatment in cancer centers, (5) reviewed strategies to overcome barriers to cessation treatment in cancer settings, and (6) explored scientific questions related to tobacco dependence treatment that require further study. Representatives from each NCI cancer center were invited. The meeting included talks from the NCI and experts in the field, panel discussions, and question-and-answer sessions; 65 members from 40 cancer centers participated. This meeting and overview may help build capacity for the delivery of tobacco dependence treatment at NCI cancer centers.
Smoking causes 30% of all cancers and 80% of mortality from head and neck and lung cancer.1–3 Despite policy and scientific advances, 21% of Americans currently smoke tobacco, upward of 50% of patients with cancer who smoked before diagnosis continue to smoke,4 and relapse rates after completion of medical treatment are high.5 There are more than 11.7 million cancer survivors in the United States, including more than 325,000 adult survivors of childhood/adolescent cancer.6 Upward of 25% of survivors are smokers, including 14% of adolescent cancer survivors.7 Continued smoking by patients and survivors decreases survival time,8 increases risk for a second primary cancer,9 reduces medical treatment effectiveness,10,11 and diminishes quality of life after treatment.12,13
Patients with cancer who try to quit smoking typically do so without formal assistance,14 which yields low success rates.15 Further, the provision of tobacco use treatment is not considered a “core service” at most NCI cancer centers. The results of a survey of tobacco use treatment at 58 NCI cancer centers presented at this meeting for the first time16 showed that, although 60% of cancer centers offered some form of tobacco use treatment, such services were often confined to one disease subpopulation (eg, lung cancer). Fewer than half of the cancer centers have designated personnel to offer tobacco use treatment. The availability of tobacco use treatment programs at cancer centers lags behind that of other models of care (eg, nutrition).
An important first step in encouraging cancer centers to address tobacco dependence is to improve systems for identifying smokers and referring them to suitable treatment programs. A uniform measure of smoking status for patients at each visit can triage patients into effective treatments and assess clinical effects of continued smoking.17 Including tobacco use as a “vital sign” on patient medical charts increases the rate of identification of smokers, rates of treatment, and cessation rates.18,19 Currently, fewer than half of the 58 cancer centers assess smoking status as a vital sign,16 yet this procedure is cheap, simple, and effective.
The US Public Health Service's Treating Tobacco Use and Dependence Clinical Practice Guideline identifies effective treatments and clinical practices.18 The Guideline underscores that tobacco dependence is a chronic disease with the need for repeated intervention. Interventions as brief as 3 minutes can help smokers who are ready to quit to utilize effective treatments, motivate smokers who are not ready to quit to consider treatment, and reduce the risk of relapse among patients who have recently quit smoking.18 Health care providers are advised to offer, or facilitate access to, counseling and guideline-recommended medications, which are most effective when combined. Approved medications include nicotine replacement therapy (gum, patch, nasal spray, inhaler, lozenge), bupropion, and varenicline. The extended use or combination of these medications does not present a known health risk and may increase abstinence.18 Because quit-line counseling is available in all states, has broad reach, and is effective in diverse populations, clinicians could use this resource as an option.
Few studies have examined tobacco dependence interventions for patients with cancer and survivors, especially among adolescents. Many existing trials have used small samples and lacked biochemical verification.20–22 Only one placebo-controlled trial of an FDA-approved pharmacotherapy agent has been conducted in patients with cancer, 23and only one large smoking cessation clinical trial has been conducted with adolescent survivors24; a second trial with childhood cancer survivors is underway.25 Cancer centers can play a pivotal role in designing and implementing studies and evaluating methods for dissemination of treatments. Studies could evaluate the use of the full cancer treatment team (v a single interventionist) or could examine the optimal timing or duration of tobacco use treatment. Developing and testing novel behavioral interventions is an important direction for future research, as are models that include family members in, or as targets of, the intervention. Research is needed on how to integrate cessation treatment into care delivery and how to sustain cessation. The integration of tobacco use treatments into cancer centers should be guided by existing guidelines and innovative research.
The meeting highlighted tobacco dependence treatment programs at four cancer centers. These programs are summarized in Table 1 but include the following components:
Despite supportive policies from oncologic organizations,26–28 treatment for tobacco dependence is still not part of standard cancer care, and only 7% of cancer clinical trials assess smoking status.29 Barriers to the provision of tobacco dependence treatment in the oncologic context are common across health care settings (eg, lack of physician time28). Unique barriers and strategies to overcome these barriers30 are reviewed below and in Table 2.
Patients who smoke might not request help because of their guilt over smoking,31 fear of being stigmatized,32 or fatalism about their disease.33 Variability in patient smoking over time (eg, high quit rates at diagnosis but high relapse rates), hinders identification. Patients with cancer show high levels of nicotine dependence,34 possibly requiring combination35 or extended36 treatments. Enforced abstinence as a result of no-smoking policies can be aversive, reducing future quit attempts. Treatment options may be limited by medical contraindications, including trouble swallowing, or by depression; these conditions may require specialized treatments.37,38
Health care providers may lack awareness of the prognostic importance of smoking, lack the skill to treat smoking, or worry about exacerbating patient guilt. Many cancer centers have inadequate procedures to identify patients who smoke and triage them to treatments. The Joint Commission may include documentation of tobacco use status, delivery of treatments, and provision of follow-up care as a quality indicator.39 The transition to electronic medical records may incorporate tobacco use as a vital sign19 and use electronic reminders to ensure compliance with repeated assessments and treatment referral.20
Given practical constraints, it is unreasonable to expect that health care providers can provide comprehensive tobacco dependence treatment. Nevertheless, tobacco dependence treatment must become a greater priority at cancer centers. The burden of treatment can extend beyond the oncologist to include nurses, pharmacists, psychologists, and social workers. Referral to in-house or community-based treatments or quit lines is essential. Resources are available to assist with the integration of tobacco use assessment and treatment into cancer centers (Table 3).
The convergence of motivated and talented clinicians, enhanced technology, treatment guidelines, models of care, and evolving hospital accreditation standards may accelerate progress in treating tobacco dependence at NCI cancer centers. With a constituency of close to 12 million Americans living with cancer,6 cancer centers have the opportunity to be the exemplars in tobacco dependence research and treatment. Cancer centers, with their talented and committed faculty, are optimally positioned to perform cutting-edge research, inform the field of tobacco dependence treatment, and meet the call to action from the NCI40 and ASCO.27 The Treating Tobacco Dependence at Cancer Centers meeting served as a springboard to develop or refine center approaches to treating tobacco dependence and expanded and energized the community of scientists devoted to this endeavor. Priorities to enhance the quality of care for tobacco dependence at cancer centers include (1) developing consensus regarding the assessment of smoking status, (2) refining electronic medical records and clinical trials to ensure the identification and referral of smokers, (3) evaluating novel treatments for cancer patients, and (4) evaluating methods to overcome barriers to providing smoking cessation treatment. The academic resources at cancer centers and the motivation and commitment of cancer center representatives suggest that the future will see cancer centers leading the way in treating tobacco dependence and contributing substantially to further reductions in tobacco-related morbidity and mortality.
Steering Committee: Glen Morgan, PhD (Meeting Chair), Tobacco Control Research Branch, National Cancer Institute; Robert Schnoll, PhD (Meeting Co-Chair), Department of Psychiatry, University of Pennsylvania; Catherine Alfano, PhD, Office of Cancer Survivorship, National Cancer Institute; Sarah Evans, PhD, SAIC-Fredrick, National Cancer Institute; Adam Goldstein, MD, MPH, Department of Family Medicine, University of North Carolina, Chapel Hill; Jamie Ostroff, PhD, Behavioral Science Service, Memorial Sloan-Kettering Cancer Center; Elyse Richelle Park, PhD, Department of Psychiatry and Health Policy, Massachusetts General Hospital/Harvard Medical School; Lind Sarna, DNSc, RN, School of Nursing, University of California, Los Angeles; Lisa Sanderson Cox, PhD, Department of Preventive Medicine & Public Health, University of Kansas Medical Center.
Speakers: Janice Blalock, PhD, Department of Behavioral Science, University of Texas M. D. Anderson Cancer Center; Michael Fiore, MD, MPH, MBA, Center for Tobacco Research and Intervention, University of Wisconsin; Thomas J. Glynn, PhD, Cancer Science and Trends and International Cancer Control, American Cancer Society; Adam Goldstein, MD, MPH, Department of Family Medicine, University of North Carolina, Chapel Hill; Ellen Gritz, PhD, Department of Behavioral Science, University of Texas M. D. Anderson Cancer Center; Robert S. Klesges, PhD, Department of Preventive Medicine, University of Tennessee Health Sciences Center; Corey J. Langer, MD Division of Hematology-Oncology, Abramson Cancer Center, University of Pennsylvania; Glen Morgan, PhD, Tobacco Control Research Branch, National Cancer Institute; Jamie Ostroff, PhD, Behavioral Science Service, Memorial Sloan-Kettering Cancer Center; Elyse Richelle Park, PhD, Department of Psychiatry and Health Policy, Massachusetts General Hospital/Harvard Medical School; Julia Rowland, PhD, Office of Cancer Survivorship, National Cancer Institute; Lisa Sanderson Cox, PhD, Department of Preventive Medicine & Public Health, University of Kansas Medical Center; Linda Sarna, DNSc, RN, School of Nursing, University of California, Los Angeles; Robert Schnoll, PhD, Department of Psychiatry, University of Pennsylvania; Vani Nath Simmons, PhD, Department of Health Outcomes & Behavior, Moffitt Cancer Center; Mary Ellen Wewers, PhD, Division of Health Behavior and Health Promotion, The Ohio State University.
Conference Sponsor and Partner: National Cancer Institute.
Although all authors completed the disclosure declaration, the following author(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; those relationships marked with a “C” were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.
Employment or Leadership Position: None Consultant or Advisory Role: Robert Schnoll, GlaxoSmithKline Stock Ownership: None Honoraria: None Research Funding: Adam Goldstein, Pfizer; Robert Schnoll, Pfizer Expert Testimony: None Other Remuneration: None
Conception and design: Glen Morgan, Robert A. Schnoll, Catherine M. Alfano, Sarah E. Evans, Adam Goldstein, Jamie Ostroff, Elyse Richelle Park, Linda Sarna, Lisa Sanderson Cox
Administrative support: Sarah E. Evans
Manuscript writing: Glen Morgan, Robert A. Schnoll, Catherine M. Alfano, Sarah E. Evans, Adam Goldstein, Jamie Ostroff, Elyse Richelle Park, Linda Sarna, Lisa Sanderson Cox
Final approval of manuscript: Glen Morgan, Robert A. Schnoll, Catherine M. Alfano, Sarah E. Evans, Adam Goldstein, Jamie Ostroff, Elyse Richelle Park, Linda Sarna, Lisa Sanderson Cox