More active support and interventions by physicians are required to get patients who still smoke to stop, according to two articles published online by the Journal of Oncology Practice (JOP),1,2 and to prevent school-aged children and adolescents from starting to use tobacco, according to a U.S. Preventive Services Task Force (USPSTF) recommendation statement published in the Annals of Internal Medicine.3
Smoking Cessation Support
ASCO recommends that clinicians assess tobacco use and provide cessation support. Moreover, Graham W. Warren, MD, PhD, of the Medical University of South Carolina, Charleston, and coauthors noted that 86% of those responding to a survey sent to ASCO members agreed that smoking cessation support should be a standard part of clinical cancer care.1 Yet only 39% reported that they provided smoking cessation support to patients.
Nearly 90% of respondents said that they routinely asked patients about tobacco use at their initial visit, and more than 80% reported advising patients to stop using tobacco. During follow-up visits, the percentage who always or usually asked about tobacco and who reinforced the importance of stopping tobacco use hovered at around 70%.
Most of those responding to the survey (81%) were medical oncologists, and 79% reported spending at least half their time seeing patients. Nearly 73% had never smoked, and 3% were current smokers.
“The response rate to the online survey (6.5%) precludes us from making generalizations about the entire ASCO membership,” the authors acknowledged, but added, “the findings appear to be robust in that they mirror the results found in other surveys of oncologists.” The authors noted a similar study of thoracic oncologists from the International Association for the Study of Lung Cancer published earlier this year that produced remarkably similar patterns of tobacco assessment and cessation support.4 Because those responding may have a higher interest in tobacco assessment and cessation, the reported results might be “overly optimistic,” and “the true practice patterns of oncologists may in fact be worse than reported,” the investigators noted.
The potential benefits of ongoing efforts to improve efficacy of tobacco cessation among patients will not be realized, the researchers concluded, unless clinicians provide either direct support to patients or referrals to dedicated tobacco cessation programs providing structured support.
Missed Opportunities
A retrospective medical record review of 948 patients diagnosed with bronchogenic carcinoma at a community medical center between 2008 and 2010 found that 438 were current smokers at diagnosis, and only 36.1% had been counseled on smoking cessation.
“To quit smoking successfully, patients need assistance from their physicians. In our study, patients encountered between two and five physicians from various specialties in the 6 months surrounding their diagnosis, representing numerous missed opportunities to counsel,” commented Jessica R. Hildebrand, MD, of New Hanover Regional Medical Center, Wilmington, North Carolina, and Sangeeta Sastry, MD, of The University of North Carolina, Chapel Hill.2
They found neither a significant correlation between the number of encounters and the likelihood of counseling, nor any significant differences based on age, race, or sex. “However, there was a significant decrease in counseling with higher stages of cancer. Notably, patients with stage I disease were 1.7 times more likely to be counseled than those with stage IV disease (P = .017),” the researchers reported.
“Despite the benefits of smoking cessation, there may be a prevailing belief among physicians that treating tobacco dependence is futile in patients who already have cancer,” the authors commented. “Physicians may fail to address this issue in practice because of competing concerns during their encounters, uncertainty about how to implement brief interventions, or a lack of familiarity with tobacco assessment and effective treatments. Oncologists and subspecialists may also believe that the discussion should occur with primary care physicians. However, it has been argued that oncologists are uniquely positioned to affect smoking rates and should take an active role in smoking cessation.”
Primary Care Interventions
That said, primary care physicians should provide interventions to prevent initiation of tobacco use in school-aged children and adolescents, according to an updated recommendation statement from the USPSTF.3
“The USPSTF found adequate evidence that behavioral counseling interventions, such as face-to-face or phone interaction with a health care provider, print materials, and computer applications, can reduce the risk for smoking initiation in school-aged children and adolescents,” according to the statement. A previous statement in 2003 concluded that “the evidence was insufficient to recommend for or against routine screening for tobacco use or interventions to prevent and treat tobacco use and dependence in children or adolescents.”
The updated statement noted that each day in the United States, more than 3,800 children and adolescents smoke their first cigarette, and an estimated 1,000 begin smoking on a daily basis. “Although most serious health effects from smoking occur in adulthood,” the task force wrote, “children and adolescents can have negative respiratory effects, including impaired lung growth; early onset of lung function decline; and respiratory- and asthma-related symptoms, such as coughing and wheezing.” ■
Disclosure: For full disclosures reported by the authors of the JOP studies discussed in this article, visit jop.ascopubs.org.
References
1. Warren GW, Marshall JR, Cummings KM, et al: Addressing tobacco use in patients with cancer: A survey of American Society of Clinical Oncology members. J Oncol Pract. July 29, 2013 (early release online).
4. Warren GW, Marshall JR, Cummings KM, et al, on behalf of the IASLC Tobacco Control and Smoking Cessation Committee: Practice patterns and perceptions of thoracic oncology providers on tobacco use and cessation in cancer patients. J Thorac Oncol 8:543–548, 2013.
