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© 2003 American Society for Clinical Oncology
Tobacco Dependence: Why Should an Oncologist Care?
From the Division of Radiation Oncology, Department of Oncology and the Division of General Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN. Address reprint requests to Yolanda Garces, MD, Department of Oncology, Division of Radiation Oncology, Mayo Clinic, 200 First St, SW, Rochester, MN, 55905; email: garces.yolanda{at}mayo.edu. THE CASE A 64-year old woman with asthma had a suspicious lung nodule on a preoperative chest x-ray and was ultimately found to have a stage IIIA non–small-cell lung cancer with metastases to hilar and mediastinal lymph nodes. After being informed that the cancer was unresectable, and after discussing options about treatment and prognosis with her oncologists, she was treated with combined modality radiation and chemotherapy. During her radiation therapy, her oncologist noted with astonishment that the patient admitted to "smoking a bunch of cigarettes during the last few days." She felt guilty about smoking, but powerless to stop it. She had planned not to purchase cigarettes in an attempt to force herself to quit, but in desperation, she began looking through her trash to find partially smoked cigarettes. Her doctors had provided her with a nicotine patch prescription but had never discussed a plan to help her quit. At the patient’s urging she was referred to a counselor who specialized in the treatment of tobacco dependence. With the use of pharmacologic therapy, intensive counseling and regular follow-up, she was able to successfully stop smoking. Although she had a few slips along the way, she remained abstinent from cigarettes for many months. When her cancer returned 6 months after completing treatment, she accepted the news. She was referred to a hospice and, a year after she had completed treatment for lung cancer, she died, smoke-free, while participating in a local outpatient hospice program. DISCUSSION As this case demonstrates, many oncologists feel ill-prepared to address smoking cessation as part of their clinical practice. However, they can learn to provide a rational intervention for smokers by asking each patient about tobacco use, encouraging an attempt to quit, and providing each patient with the resources that will enable them to reach the goal of being tobacco free. Cigarette smoking is the leading cause of preventable death in the United States, accounting for over 20% of all mortality.1 Although cancer deaths make up a large portion of smoking-attributable morbidity and mortality, cardiovascular disease and chronic lung disease account for the majority of smoking-related disease. Not uncommonly, oncology specialists care for patients who have diseases attributable to tobacco use. Although treatment of the patient’s currently active cancer is usually the first priority, an underlying condition like tobacco dependence should not be ignored. Approximately 25% to 80% of smokers will continue to use tobacco after a diagnosis of cancer. Despite this statistic, the time of diagnosis of a malignancy is a "teachable moment," a time when the patient may be particularly receptive to the message an oncologist can provide regarding tobacco cessation.2–4 Providing treatment for tobacco dependence will not reverse the cancer already present, but it may provide other health benefits. Some of the health benefits of stopping tobacco use are immediate. Blood carbon monoxide concentration decreases, lung function improves, and irritative respiratory symptoms such as cough and shortness of breath diminish.5 There are also longer-term benefits that may be particularly important for an oncology patient. Among these benefits is a lower rate of second primary malignancy in smokers who have successfully quit, compared with those who continue to use tobacco regularly.6 Other well-known benefits of smoking cessation include a reduction of tobacco-related cardiovascular and pulmonary disease. Oncologists who convey a personalized health-benefit message consistently and repeatedly are more likely to provide their patients with the motivation to make an attempt to stop using tobacco. Clinical practice guidelines have been published that provide evidence-based guidance on tobacco-dependence treatment for clinicians.7 Clinicians can provide a brief, simple, and straightforward behavioral intervention that includes personalized advice for the patient to stop smoking. For many oncology patients, simply hearing advice to quit and the message about the potential health benefits will provide motivation for making a serious attempt to stop tobacco use. More extensive counseling may provide better long-term abstinence rates. Many institutions have trained counselors who can provide more extensive behavioral intervention than can be provided during a physician’s office visit.
Many pharmacologic therapies are effective for the treatment of tobacco dependence. Nicotine patch treatment is indicated in most patients who are motivated to stop smoking and should be used in a dose that is adequate for relieving withdrawal symptoms. The patch dose should be matched to the daily smoking rate (Table 1
Motivating health behavior change can be difficult for individuals and frustrating for clinicians. A model of health behavior change developed by Prochaska and Diclemente11 ("stages of change") has proven to be a useful assessment tool for tobacco-dependence intervention (Table 3  ). This model allows the clinician to assess the stage of change and provide appropriate treatment. The main goal is to encourage progression along the stages of change until the patient is motivated to take action. Treatment with pharmacologic therapy and more intense behavioral therapy should be reserved for those patients who are preparing a plan for stopping tobacco use; for example, patients nearing "preparation" and "action" stages. For a patient in the "precontemplation" stage, a brief motivational message alone is appropriate.
Many patients are seen when it is too late for a cancer cure, but does that mean that it is too late for them to stop their tobacco use? Some may question the use of tobacco-dependence treatment in an individual who has a malignancy that is not amenable to cure. However, as described above, there are immediate health benefits for patients who have incurable disease. In addition to the health benefits that accrue to patients who are successful at smoking cessation, there may be psychological benefits as well. Most smokers recognize the fact that they are addicted to the use of tobacco. Many patients express a sense of accomplishment and empowerment when they are able to overcome this addiction. They may also feel more engaged in their treatment, feeling that they have been able to provide something to help themselves before surgery, chemotherapy, or radiation therapy for their malignancy. Side effects and toxicity from medications or radiation therapy may be reduced because carbon monoxide levels are lowered and oxygen carrying capacity is improved. Respiratory symptoms are improved when people stop smoking, and this may reduce some of the potential toxic effects from radiation therapy to the head, neck, or chest. The vast majority of smokers indicate that they would like to stop using tobacco. Patients with a cancer diagnosis are likely no different. When the tumor is not the target, patient care should continue. That care should include appropriate intervention for tobacco dependent patients who are motivated to end their addiction.
ACKNOWLEDGMENTS We thank Richard D. Hurt, MD, and David P. Steensma, MD, for their critiques and edits. NOTES Supported by the National Institutes of Health, Department of Health and Human Services, Bethesda, MD, grant no. CA 90628-01B. Y.I.G. is a K12 Award Recipient. REFERENCES 1. McGinnis JM, Foege WH: Actual causes of death in the United States. J Am Med Assoc 270:2207–2212, 1993[Abstract] 2. Griebel B, Wewers ME, Baker CA: The effectiveness of a nurse-managed minimal smoking-cessation intervention among hospitalized patients with cancer. Oncol Nurs Forum 25:897–902, 1998[Medline] 3. Gritz ER, Carr CR, Rapkin D, et al: Predictors of long-term smoking cessation in head and neck cancer patients. Cancer Epidemiol Biomarkers Prev 2:261–270, 1993[Abstract]
4. Sanderson Cox L, Patten CA, Ebbert JO, et al: Tobacco use outcomes among patients with lung cancer treated for nicotine dependence. J Clin Oncol 20:3461–3469, 2002 5. Center For Disease Control. The Surgeon General’s 1990 Report on the Health Benefits of Smoking Cessation (Executive Summary). Morb Mortal Wkly Rep 39:i–12, 1990
6. Khuri FR, Kim ES, Lee JJ, et al: The impact of smoking status, disease stage, and index tumor site on second primary tumor incidence and tumor recurrence in the head and neck retinoid chemoprevention trial. Cancer Epidemiol Biomarkers Prev 10:823–829, 2001 7. Fiore MC, Bailey WC, Cohen SJ, et al: Treating tobacco use and dependence. Clinical Practice Guideline. Rockville, MD, U.S. Department of Health and Human Services, Public Health Service, June 2000 8. Dale LC, Hurt RD, Offord KP, et al: High-dose nicotine patch therapy. Percentage of replacement and smoking cessation. J Am Med Assoc 274:1353–1358, 1995[Abstract]
9. Hurt RD, Sachs DP, Glover ED, et al: A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med 337:1195–1202, 1997
10. Jorenby DE, Leischow SJ, Nides MA, et al: A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 340:685–691, 1999 11. Prochaska JO, DiClemente CC: Stages and processes of self-change of smoking: Toward an integrative model of change. J Consult Clin Psychol 51:390–395, 1983[CrossRef][Medline] Submitted July 16, 2002; accepted February 19, 2003. This article has been cited by other articles:
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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