From OncoLog, March 2007, Vol. 52, No. 3

Helping Patients Stop Smoking

by Karen Stuyck

Even after they’ve been diagnosed with cancer, smokers can benefit greatly from giving up tobacco—so much so that M. D. Anderson has instituted a no-cost program to help its patients do just that.

Started in January 2006, the Tobacco Treatment Program is open to all M. D. Anderson patients who either currently use tobacco or have quit using it within the last 12 months. The program offers free counseling and tobacco-cessation pharmacological treatment as well as relapse-prevention counseling for recent quitters.

Participants receive a psychological assessment, in-person behavioral counseling, follow-up telephone counseling and support, various nicotine-replacement therapies, or tobacco cessation prescription medication. Patients’ family members who smoke also can receive free smoking cessation counseling.

M. D. Anderson’s Tobacco Treatment Program is supported by State of Texas Tobacco Settlement Funds. “This program puts into practice everything we believe is state of the art in addressing tobacco use in the cancer patient,” said Ellen R. Gritz, Ph.D., professor and chair of M. D. Anderson’s Department of Behavioral Science.

Dr. Gritz and her colleagues are spreading the word to their oncologist colleagues that stopping smoking is a significant factor in the effectiveness of treatment and overall outcome for cancer patients. While the harmful effects of smoking are well known, there are additional risks for cancer patients who smoke. Studies show that tobacco use before, during, and after treatment can affect cell growth, cell death, and tumor density, decreasing the efficacy of cancer treatment. Smoking increases the likelihood that the cancer will recur or a second primary tumor will develop. It decreases the cancer patient’s survival rate as well as the quality of life. It aggravates treatment side effects and can complicate radiation therapy, chemotherapy, and surgery, according to Dr. Gritz.

Motivation to quit

In an article in the journal Cancer, Dr. Gritz and colleagues concluded that the optimal time to help smoking patients quit is when they are initially diagnosed with cancer. Motivation and interest in smoking cessation increase after patients are diagnosed with cancer, giving health care providers a window of opportunity to intervene and assist patients to give up tobacco, according to Dr. Gritz. Their research determined that using this “teachable moment” can help up to 70% of patients stop smoking, compared to a typical success rate of 20% to 25% in the general population at one year follow-up.

This teachable moment can consist of a brief (3 minutes or less) smoking cessation intervention by the physician, with the discussion tailored to the individual patient. Ideally, Dr. Gritz said, the message needs to be reinforced and delivered multiple times, preferably coming from all health care team members. “The teachable moment has to be heavily emphasized at diagnosis because of all the things that can go wrong during treatment if the patient continues to smoke. But you have to keep repeating the message because smoking is a chronic relapsing disorder—an addiction—and when people start to feel better, smoking sometimes creeps back in.”

To inform physicians, Dr. Gritz, with some of her colleagues, has also written a chapter on “Tobacco Control in the Oncology Setting” for an upcoming American Society of Clinical Oncology (ASCO) Cancer Prevention Curriculum and a chapter called “Tobacco and Smoking Cessation—Focus on Oncology” in the upcoming 8th edition of Principles and Practice of Oncology.

Oncologists who deal with smoking-related tumors, such as in lung or head and neck cancers, are usually well aware that it’s important for their patients to stop using tobacco, but doctors who treat tumors not causally related to smoking are often less aware of the benefits of quitting, Dr. Gritz said. In more than 20 studies conducted using cross-sectional surveys, the respondents, who were mostly general practitioners and family physicians, cited several factors to explain why they did not actively encourage their cancer patients to stop smoking: lack of time to discuss smoking behavior, their belief that such discussions would be ineffective, lack of counseling skills, and concern that they were invading the patient’s privacy.

Guideline for physicians

The U.S. Public Health Service has issued a Clinical Practice Guideline to help health care providers deliver effective smoking cessation treatment. The Guideline recommends documenting every patient’s tobacco use, strongly encouraging each smoker to quit, determining the patient’s willingness to attempt quitting, using counseling and pharmacotherapy to assist in quitting, and scheduling follow-up contact.

M. D. Anderson’s Tobacco Treatment Program uses therapeutic interventions based on these guidelines. As of early March 2007, 543 patients have been treated in the program, according to Janice Blalock, Ph.D., assistant director of the Tobacco Treatment Program and an assistant professor in the Department of Behavioral Science.

The program’s staff includes one psychiatrist, an advanced practice nurse, three Ph.D. clinical and counseling psychologists, one master’s-level psychologist, and one master’s-level social worker, Dr. Blalock said, with counseling staff likely to expand as the number of patients enrolled increases.

The program’s ultimate goal, Dr. Blalock said, is to proactively identify all M. D. Anderson patients who are tobacco users or recent quitters and then contact eligible patients to invite them to participate in the Tobacco Treatment Program.

As part of a pilot program to test this proactive approach, patients in M. D. Anderson’s Head and Neck Clinic fill out a questionnaire in the Patient History Database when they register. The questionnaire identifies and automatically notifies the staff of the Tobacco Treatment Program when a patient is a smoker or a recent quitter. Program staff then contact those patients to make them aware of the program and schedule an appointment for those willing to meet with a clinician. The database eventually will be used in all M. D. Anderson clinics, which will enable the Tobacco Treatment Program to identify eligible patients throughout the institution.

No matter how they are referred, smokers come to the program in various stages of willingness to stop using tobacco, Dr. Blalock said. In their initial assessment, all patients are evaluated for motivation to quit as well as for concurrent psychiatric problems.

“If there are motivational problems, we focus on delivering motivational interventions before we do anything else,” she said. Motivational interviewing is one technique shown to be effective. Such discussions help patients consider the risks and benefits of taking action and let the patients know about available resources, while at the same time demonstrating acceptance of the patients’ feelings, beliefs, and personal goals regarding changing tobacco use. If patients are reluctant to quit immediately, the program’s staff will help them achieve other tobacco-use goals, such as reducing their smoking rates. Many of the medications used in the Tobacco Treatment Program decrease the desire to smoke, which can also help the patients who prefer to make gradual changes.

The program offers, at no cost to patients, all the front-line medications recommended by the Clinical Practice Guideline, Dr. Blalock said. These include various nicotine-replacement products—patch, gum, lozenges—as well as bupropion (Zyban), an antidepressant shown to be effective in helping people quit smoking, and a promising new drug, varenicline (Chantix), which decreases the desire to smoke.

The program also addresses other problems the patients might have that could affect their ability to stop smoking. “We know that people who smoke often have concurrent problems, like alcohol abuse, depression, or an anxiety disorder,” Dr. Blalock said. In such cases, the program psychiatrist will assess the patient and possibly prescribe medication. If additional therapy is considered necessary, the patient will be referred to other counseling services.

“Our goal was to create a program that addresses all the barriers individuals may have to stopping smoking,” Dr. Blalock said. Whether that barrier is low motivation to quit, a concurrent psychiatric problem, a spouse or family member who still smokes, or a lack of financial resources to pay for a smoking cessation program, M. D. Anderson’s Tobacco Treatment Program is working to provide solutions.

For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789.

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