Tobacco use is the leading cause of preventable morbidity and mortality in the United States.1 The nicotine in tobacco is highly addictive, and nicotine dependence is a serious impediment to tobacco cessation. There is now wide consensus on the efficacy of evidence-based tobacco cessation behavioral strategies and pharmacologic treatments, the expanded implementation of which would significantly decrease smoking rates and the development of tobacco-related diseases.2
It is estimated that approximately one-third of patients who smoked prior to their illness continue to smoke after receiving a cancer diagnosis.3 Tobacco use among patients with cancer can have an adverse effect on their overall survival and quality of life.4 In addition, smoking during treatment leads to an increased incidence of serious adverse effects, such as oral mucositis, pulmonary and cardiovascular complications, weight loss, impaired wound healing, and infection.5,6 Continuing to smoke has been reported to decrease the effectiveness of cancer treatment. For example, response rates at the end of radiation therapy have been reported to be lower in smokers than in nonsmokers or smokers who quit before treatment,7 and smoking has been shown to induce the hepatic metabolism of chemotherapy drugs, thereby reducing their therapeutic effects.8 Continued smoking also increases the rate of surgical complications, an important consideration because surgery is a major treatment for cancer. The numerous effects of smoking on surgical outcomes, including increased reintubation, aspiration/respiratory infections, increased length of hospital stay, and wound dehiscence, are so detrimental that surgeons now often will not operate unless a smoker has been abstinent for several weeks.9
Stopping smoking prior to a cancer diagnosis or treatment can improve survival outcomes.10 Among smokers in general, higher self-efficacy and increased perception of harm are related to success in quitting smoking.11 Several studies have shown that patients' desire and motivation to quit tobacco increase after a cancer diagnosis, particularly if their cancer is known to be causally related to tobacco use (eg, lung, bladder, and head and neck cancers).12,13 Thus, a cancer diagnosis presents an opportunity for healthcare providers to offer a tobacco cessation intervention. The 2008 U.S. Public Health Service Clinical Practice Guideline (PHS 2008) on treating tobacco use and dependence found robust evidence that evidence-based counseling and pharmacotherapy independently improved abstinence rates in smokers, and together doubled the abstinence rates of either modality alone. Results were so compelling that the use of medications and counseling together is considered standard of care for all smokers and tobacco users.2 The recommended counseling usually consists of motivational enhancement, problem solving, skills training, and social support, whereas the pharmacotherapy options for smoking cessation include 5 nicotine replacement therapies (NRTs: nicotine gum, inhaler, lozenge, nasal spray, and patch) and the non-nicotine medications bupropion sustained release (SR) or extended release (XL), and varenicline.2
Patients with cancer have unique challenges for smoking cessation. They often struggle with high-levels of stress, anxiety, and depression14; they are often older with multiple failed attempts to quit; they may have complex medication regimens; and they may be experiencing side effects of illness and treatment. Many of these (particularly stress, anxiety, and depression) are associated with smoking and smoking relapses, and patients may respond to some treatments better than others.6 Patients with cancer and their partners tend to experience cancer-related distress15 that can overwhelm their sense of coherence. As Stark and House16 noted, cancer treatment, although holding promise of remission, often results in unmanageable anxiety that may complicate or hinder tobacco cessation. Therefore, it is recommended that comprehensive cancer treatment include a robust treatment program for tobacco use along with identification and treatment of psychiatric symptoms and disorders.17
Although many cancer centers offer some form of tobacco cessation support, only a few cancer centers currently provide a full spectrum of tobacco cessation services to all of their patients.18,19 In order to provide high-quality individualized care for a population with comorbidities and numerous relapse challenges, it is important to implement a programmatic structure that allows for a wide range of motivational (readiness to quit) states, nicotine dependence, and economic, psychiatric, and scheduling challenges. This article describes and presents diagrams illustrating treatment tracks, or treatment pathways, in the Tobacco Treatment Program (TTP) at MD Anderson Cancer Center that we have developed and refined over the past 10 years. We also present basic outcome data on abstinence rates that our patients have achieved.
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