Clinicians should take advantage of any opportunity to help patients stop smoking, said J. Lee Westmaas, PhD, Director of Tobacco Control at the American Cancer Society. That disclaimer aside, his new research found that any time after a cancer diagnosis could be a particularly effective time to get the message across to a smoker, he explained in a phone interview about the findings.
The study showed that both two- and four-year quit rates were higher for patients diagnosed with cancer, compared with a group of patients who were not diagnosed with cancer (JCO 2015;33:1647-1652).
"It didn't matter what stage the cancer was, the type of cancer, how much they smoked, or when they started smoking," Westmaas said.
The researchers used data from ACS's Cancer Prevention Study-II Nutrition Cohort (which included both men and women, the majority of whom were 50 and older). For the 772 smokers in the cohort who were diagnosed with cancer (for which data was available on smoking status for a minimum of four years), 31.3 percent quit within two years of their cancer diagnosis, compared with 19 percent for the 11,410 smokers in the cohort who were not diagnosed with cancer. Similarly, 43 percent of those diagnosed with a cancer quit smoking within four years of their diagnosis, compared with 33.8 percent for the smokers not diagnosed with cancer.
And smokers who quit in the first two years after a cancer diagnosis were less likely to resume smoking compared to the smokers who had not been diagnosed with cancer-12.4 percent of the two-year quitters who had cancer resumed smoking within four years versus 15.4 percent of the two-year quitters who had not had cancer.
"It seems to be that cancer diagnosis may have triggered [for the smokers] some thinking about health behaviors that they may need to change, or perhaps they may have thought of smoking as having a link to their cancer even though it was not a smoking related cancer," Westmaas explained.
This study excluded patients from the group with cancers of the lung, head and neck, esophagus, or any metastatic or advanced cancer.
"We eliminated those cancers, not because they were smoking-related cancers, but because they probably would limit a person's ability to smoke," Westmaas said. "We were really trying to answer the question-was diagnosis a trigger for quitting? Whereas with those other cancers or advanced cancer, because of the symptoms and side effects, you almost have to quit."
So how should these findings change practice? Here's what he said.
1. What's the key message about these findings that all practicing oncologists should be aware of?
"Oncologists should always ask patients about smoking and try to provide as many resources for the patient as possible-even for long-term survivors. And oncologists should provide follow-up support, checking in with patients to ask whether they are smoking or not.
"This research showed that smokers who are diagnosed with cancer regardless of cancer stage, how much they smoked, or when they started smoking, quit at much higher rates than those who were not diagnosed with cancer.
"But, I think that some oncologists are not addressing smoking with their cancer survivors."
2. What makes the topic a difficult one for oncologists to address?
"Some oncologists may be afraid to bring it up to some of their patients. Doctors may think their patients are already going through a lot-to have them quit smoking would be another stressor that we don't want to be responsible for incurring.
"It's true that dealing with a cancer is stressful and some survivors might look at smoking as a way of relieving that stress. But studies consistently show that when people quit smoking their stress levels go down. So, in that regard training would be important.
"And the other issue is connecting both patients who smoke and the clinicians taking care of them with the resources that are available, like the 1-800-QUIT-NOW free tobacco cessation counseling phone line, which is available to any member of the public; or websites like http://smokefree.gov (the National Cancer Institute website with cessation resources). And there are various pharmacotherapies for smoking cessation that cancer survivors may also benefit from.
"I think many smokers don't even know about the resources that are out there-and some physicians might not be aware of them either. Getting that knowledge out there is important."
3. In an accompanying editorial, Stephanie Land and Pamela Marcus, both at NCI, wrote that the findings raise the question of whether the smoking cessation rates would also be higher after patients undergo cancer screening. The hypothesis seems intriguing based on as they note in the editorial the rapid expansion of low-dose CT screening for lung cancer, the USPSTF's recommendation that high-risk individuals undergo screening, and CMS's decision to provide Medicare coverage for lung cancer screening. What do you think about that hypothesis?
"Any chance that physicians have to convey the message that your health will be improved if you quit smoking should be acted on. And cancer screening, I think, is also a teachable moment, because patients who are getting screened for a cancer are presumably showing some interest in their health-so it very well may be that cancer screening is a teachable moment for asking about smoking and providing patient resources for the smoker who is being screened.
"In the case of lung cancer screening, there is evidence suggesting that screening for lung cancer doesn't change smokers' risk perceptions-regardless of whether the screening was positive or negative. On the other hand, there was a recent small qualitative study suggesting that smokers may be interpreting the screening test (computed low-dose tomography) as showing that they won't get lung cancer, or that the test "protects" them (JAMA Int Med doi:10.1001/jamainternmed.2015.3558).
"And if this is happening, I think it becomes even more important to use any screening as a 'teachable moment' and provide smokers with all of the tools that could potentially help them quit."