Several oncology organizations have created guidelines for oncology specialists to help patients with cancer to quit smoking. ASCO has far-reaching goals aimed at tobacco reduction, including cessation tools and other resources. To shed light on the current work in this area, The ASCO Post spoke with Sarah Price, MA, a graduate student at the University of Arizona whose research focuses on the psychosocial and behavioral aspects of cancer survivorship. These aspects include assessing and treating tobacco use in the context of cancer care as well as understanding ways to better connect patients with evidence-based psychosocial care. Ms. Price is a coauthor of a recent study on tobacco use assessment and treatment in patients with cancer.1
Catalyst of Modifications in Health Behavior
Please tell the readers what inspired your study.
Throughout my research and clinical work, I’ve been committed to helping patients with cancer find the best tools to help them quit smoking. Even though the risks are well known, smoking rates among newly diagnosed patients with cancer are surprisingly high, as are the rates in those who have been out of treatment and are in long-term survivorship. It’s clear from the literature that patients with cancer, and even those well beyond treatment, can markedly improve their treatment and posttreatment outcomes, including survival and quality of life, when they quit smoking.2-5
Oncologists are in a key position to communicate with patients and leverage their patient-clinician relationship as a window of opportunity to address smoking cessation techniques for their patients who are still using tobacco products…— Sarah Price, MA
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Based on my experiences delivering smoking cessation treatment in oncology settings prior to coming to the University of Arizona, I observed that advice from an oncology clinician may be a catalyst of impactful health behavior modifications. In fact, advice from a trusted doctor was often what brought patients to see me for smoking cessation counseling. It was the cancer diagnosis that sparked patients to reach out for help, despite being long-term smokers. It was through this experience that I became aware of just how much value oncology clinicians’ words have for their patients with cancer.
Oncologists are in a key position to communicate with patients and leverage the patient-clinician relationship as a window of opportunity to address smoking cessation techniques for their patients who are still using tobacco products. I wanted to take a step back to review the literature to understand just how consistently oncology clinicians were taking advantage of that window of opportunity to facilitate smoking cessation.
Scoping Review on Tobacco Use in Patients With Cancer
Please describe the structure and methodology of your study.
Since we know that smoking cessation is important in the context of cancer care, we wanted to understand the current role of oncology clinicians in assessing and treating smoking among patients with cancer. My coauthors and I consulted the published literature to identify opportunities where we might be able to improve tobacco cessation in a cancer setting. We decided that the best method to capture the state of the literature in this area was to undertake what is called a scoping review. This type of review aims to map the literature on a particular topic or research area and provide an opportunity to identify key concepts, gaps in the research, and types and sources of evidence to inform practice, policymaking, and research.
We wanted the article to have a number of different metrics within called the 5As, which are recommended in the U.S. Public Health Service’s Clinical Practice Guideline: Treating Tobacco Use and Dependence (www.ncbi.nlm.nih.gov/books/NBK63952/). The 5As are as follows: Asking about tobacco use; Advising users to quit; Assessing willingness to quit; Assisting in quit attempts; and Arranging follow-up contact. Not only did we want quantitative data, such as predictors to barriers to disease treatment delivery, we also wanted to capture some qualitative data about patient and provider experiences. In other words, what is it like to actually receive this advice, and also what is it like to deliver advice about smoking cessation to a vulnerable patient with cancer?
We need to see a cultural shift toward smoking cessation intervention as an integrated element of care, the same as taking a patient’s blood pressure or blood panel.— Sarah Price, MA
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To zero in on relevant articles published between 2006 and 2017, we used search terms such as providers, smoking cessation, oncology, tobacco, and cancer. Then, we systematically reviewed the data and decided as a team which articles met our inclusion criteria. As we reported the results, we organized the content within the 5As framework to identify which areas were underreported in the literature. We also wanted to organize the provider- and system-level barriers as well as to highlight those areas for future investigation and intervention.
Demographics of Smoking
Did you learn anything about the demographics of smoking that might be of help in the broader landscape of smoking cessation in cancer care?
We’ve made a lot of progress over the years in decreasing smoking in the general population, but certain populations remain disproportionately impacted. For example, people who are more persistent smokers tend to be nicotine-dependent; they experience stronger withdrawal symptoms, making it much more difficult to quit. Then there are people with cancer who have a lower socioeconomic status; they tend to be more persistent smokers and benefit the least from smoking cessation attempts. Although we can identify and stratify patients according to certain markers, we need to understand more deeply why certain populations benefit less than others when it comes to smoking cessation efforts, which points to the need for more research in this area.
Despite nationwide efforts to curb smoking, many people still smoke, and lung cancer remains the leading cause of cancer deaths. Please share a closing thought on this cancer care dilemma.
We need to see a cultural shift toward smoking cessation intervention as an integrated element of care, the same as taking a patient’s blood pressure or blood panel. To make real headway, evidence-based tobacco use assessment and treatment should become standard of care for primary and cancer care specialists. This assessment should be delivered empathically, followed by active treatment using clinical cessation practice guidelines, such as ASCO’s guidelines. We also need more widely available tobacco treatment services, especially situated within cancer treatment centers. Given the downstream benefits, the cost and application of these programs would pay huge long-term health benefits not only for our patients with cancer, but for the population at large. ■
DISCLOSURE: Ms. Price reported no conflicts of interest.
1. Price SN, Studts JL, Hamann HA: Tobacco use assessment and treatment in cancer patients: A scoping review of oncology care clinician adherence to clinical practice guidelines in the U.S. Oncologist 24:229-238, 2019.
2. Karam-Hage M, Cinciripini PM, Gritz ER: Tobacco use and cessation for cancer survivors: An overview for clinicians. CA Cancer J Clin 64:272-290, 2014.
3. Abdel-Rahman O: Impact of current versus former smoking status on the outcomes of non-metastatic non-small cell lung cancer treated with upfront surgery: Findings from the National Lung Screening Trial. Expert Rev Respir Med 13:585-591, 2019.
4. Warren GW, Sobus S, Gritz ER: The biological and clinical effects of smoking by patients with cancer and strategies to implement evidence-based tobacco cessation support. Lancet Oncol 15:e568-e580, 2014.