The Washington Manual of Oncology, 3 Ed.

Smoking Cessation and Counseling

Aaron Abramovitz • Mario Castro

 I. INTRODUCTION. Tobacco products are the number one cause of preventable morbidity and mortality in the United States. An estimated 500,000 people die each year from tobacco-related illness. In 2012, 22% of adults and 6.6% of children 12 to 17 years of age were cigarette smokers. In 1965, the year of the landmark Surgeon General Report on tobacco, the smoking rate in adults was 42%. This decrease is due to efforts in the political, medical, and private spheres to educate the population on the risks of tobacco smoking. Public awareness of the health risks of tobacco in 2012 can be seen in the 69% of daily smokers who were interested in quitting and the 43% of daily smokers with at least one quit attempt in the last year.

2008. SMOKING CESSATION PRACTICE GUIDELINES. The US Department of Health and Human Services published updated practice guidelines regarding smoking cessation in 2008. The full report is available at www.surgeongeneral.gov/tobacco. Recommendations will be summarized here. The two key questions that every patient must be asked are: “Do you smoke?” and “Do you want to quit?” Following this, the clinician can apply the following guidelines:
2009. Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit.
2010. Clinicians and health-care delivery systems must document tobacco status and treat every tobacco user seen in a health-care setting.
2011. Brief tobacco-dependence treatment is effective.
2012. Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication is more effective than either alone.
2013. Tobacco-dependence treatments are both clinically effective and highly cost effective relative to interventions for other clinical disorders. Providing insurance coverage for these treatments increases quit rates.

 III. SMOKING CESSATION COUNSELING/BEHAVIORAL MODIFICATION. A template for tobacco cessation counseling in the office setting called the “Five A’s” (Table 45-1) is provided in the smoking cessation practice guidelines. This was developed to provide a strategy to engage smokers in a counseling session that takes less than 10 minutes while opening the door to give more detailed information on how to quit.

 It is important to take a practical approach to smoking cessation counseling in order to provide each patient with a full range of information. Patients must be counseled to identify triggers for smoking behavior such as smoking cues (e.g., after a meal and while driving), drinking alcohol, and being around other smokers. Coping skills such as avoiding triggers, making lifestyle changes to reduce stress, and limiting access to cigarettes are useful to discuss. In addition, information about the person’s lung age based on the current lung function and expected decline of lung function if they continue to smoke has been helpful in increasing cessation rates (Fig. 45-1). Discussing the duration and nature of withdrawal symptoms can help motivate and prepare the patient to quit smoking.

 For patients unwilling to make a quit attempt, motivational interviewing strategies can be employed to give the patient further information about smoking cessation. In a nonconfrontational manner, explore how quitting is personally relevant to the patient (e.g., having children in the home or cost). Discuss briefly the risks of tobacco smoking and the rewards of quitting (e.g., feeling better and performing better in physical activities). If the patient is resistant to counseling efforts, readdress tobacco at the next clinic visit. Provide the quitline number (1-800-QUIT-NOW) to every patient.

 IV. MEDICATIONS TO AID SMOKING CESSATION. All smokers who are trying to quit should be offered medication except when contraindicated. First-line medications include nicotine replacement products, buproprion, and varenicline. These are effective in moderate to heavy smokers (>10 cigarettes daily). Light smokers may be prescribed lower doses of nicotine replacement therapy (NRT), and pregnant patients should be encouraged to quit without medication. The choice of first-line medication should be discussed with each patient and prescribed on an individual basis in conjunction with behavioral modification. NRT can be used in combination with buproprion or varenicline. Table 45-2 provides an overview of medical therapies.

Figure 45-1. Fletcher–Peto Curve describing FEV₁ decline in smokers and nonsmokers.

Reproduced from BMJ: Parkes G, Greenhalgh T, Griffin M, et al. Effect on quit rate of telling patients their lung age. BMJ 2008;336:598. Adapted from BMJ: Fletcher C, Peto R. The natural history of COPD. BMJ 1977;1:1645–1648.

 NRT is available in the form of gum, an inhaler, a nasal spray, a lozenge, and a patch. These medications are designed to reduce nicotine craving and alleviate withdrawal symptoms by providing a steady dose of nicotine. The cost and method of administration should be discussed, as this helps the patient decide which product to use. Common side effects include local irritation at the site of administration, which is reported by most patients as mild and improves with duration of use. NRT is not an independent risk factor for cardiovascular events, even in patients with known cardiovascular disease. These medications should be used with caution in patients with recent myocardial infarction (<2 weeks), severe arrhythmias, and unstable angina. Smoking cessation efficacy at 6 months of NRT when used with behavioral modification is 19% to 27%, depending on the method of administration.

 Buproprion-sustained release should be administered 2 weeks prior to the quit date. The dose is 150 mg daily for 3 days and then 150 mg twice daily. This medication is a dopamine and norepinephrine reuptake inhibitor. Buproprion works to reduce craving and alleviates withdrawal symptoms such as anxiety, difficulty concentrating, and low mood. It is contraindicated in patients with seizures or eating disorders. Common side effects include dry mouth and insomnia. Smoking cessation efficacy at 6 months of buproprion when used with behavioral modification is 24%.

 Varenicline should be administered 1 week prior to the quit date. The dose is 0.5 mg for 3 days, then 0.5 mg twice daily for 4 days, and then 1 mg twice daily. This medication is a nicotinic receptor partial agonist and antagonist and works to reduce craving, alleviate withdrawal symptoms, and block the pleasurable effects of smoking. The dose should be reduced in patients with creatinine clearance less than 30 mL/min or if they experience side effects. Side effects include nausea, constipation, and vivid dreams. A black box warning was issued in 2009 due to postmarketing reports of an increase in depression and suicidal actions in patients taking varenicline. It is important to establish any history of psychiatric illness prior to starting this medication and to monitor the patient for changes in mood and behavior during therapy. Smoking cessation efficacy at 6 months of varenicline when used with behavioral modification is 33%.

1. TOBACCO USE IN CANCER PATIENTS AND SURVIVORS. Many patients are cigarette smokers at the time of cancer diagnosis and continue to use tobacco through treatment and survivorship. In addition to nicotine dependence, efforts to quit may be hampered by depression, nihilism, and the increased stress associated with a cancer diagnosis. It is important to counsel this group of patients about the ongoing risks of tobacco use. In patients with cancer, tobacco use contributes to all-cause mortality, can reduce the efficacy of chemotherapy, and may create a more aggressive tumor phenotype.

 All-cause mortality in patients with cancer was assessed in the 2014 Surgeon General’s Report on tobacco. The relative risk (RR) all-cause mortality was 1.22 in former smokers and 1.51 in current smokers when compared with never smoked controls. Overall, these studies showed an increase in all-cause and cancer-related mortality in patients with cancer who smoke when compared with patients who do not. Evidence of a dose–response relationship between the number of cigarettes smoked and cancer-related mortality was observed.

 The RR of recurrence of primary cancer was 1.15 in former smokers and 1.42 in current smokers. Tobacco use was also shown to increase the risk of developing a second primary cancer associated with smoking (lung, head and neck, esophageal, and bladder).

 VI. CONCLUSION. Smoking cessation is an important goal for all patients and one of the most important actions with which a clinician can assist his or her patients. Data from the Surgeon General’s Report strongly link continued tobacco use with worse outcomes in cancer patients and survivors. Counseling, behavioral modification, and medications available to treat tobacco dependence are efficacious and cost effective. Counseling should be offered to every patient who smokes and medication to every patient willing to make a quit attempt. These efforts will help many patients who smoke achieve sustained abstinence and improve cancer-related morbidity and mortality.

SUGGESTED READINGS

Aubin HJ, Luquiens A, Berlin I. Pharmacotherapy for smoking cessation: pharmacological principles and clinical practice. Br J Clin Pharmacol 2014;77:324.

Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, 2008.

Parkes G, Greenhalgh T, Griffin M, et al. Effect on quit rate of telling patients their lung age. BMJ 2008;336:598.

U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014. Rockville, MD: Office of the Surgeon General; 2014.

Warren GW, Kasza KA, Reid ME, et al. Smoking at diagnosis and survival in cancer patients. Int J Cancer 2013;132:401.