Assessing and Treating Tobacco Use in Lung Cancer Care

Summary of Key Points

Addressing tobacco dependence in patients with cancer increases the quality of care by reducing their risk for treatment complications, improving their prognosis, and reducing the risk of disease recurrence and second primary cancers.
Smoking cessation after a diagnosis of lung cancer has been shown to have a beneficial effect on performance status.
Many patients with cancer who smoke want to quit but unfortunately do not receive support and evidence-based tobacco treatment.
Further provider training and research are needed to determine strategies to implement best practices for treating tobacco dependence among patients with cancer.
In the absence of tobacco cessation interventions, lung cancer specialists are encouraged to follow general clinical practice guidelines for treating tobacco use and dependence.
Lung cancer screening provides an invaluable opportunity to promote tobacco cessation.
There is much debate and little data as to whether e-cigarettes or other electronic nicotine delivery devices will facilitate or impede smoking cessation.

In 1964, the landmark US Surgeon General’s report, Smoking and Health, first linked smoking to lung cancer. This irrefutable knowledge about the harms of tobacco spawned five decades of tobacco prevention and control research and policy, resulting in a rich compendium of comprehensive national and international evidence-based, population-based, and clinical practice guidelines aimed at reducing tobacco-related morbidity and mortality. Smoking not only has a causal link with disease and death but also has adverse effects on outcomes for patients with a wide range of chronic diseases, including cancer. Now more than ever, tobacco cessation is firmly within the purview of modern oncology. By highlighting the specific adverse effects of persistent tobacco use on cancer outcomes, this chapter provides justification for why lung cancer specialists should assess and treat tobacco use and direction for how lung cancer specialists can help their patients stop smoking.

Why Lung Cancer Specialists Should Help Their Patients Stop Tobacco Use

Cigarette smoking is the primary risk factor responsible for 87% and 70% of lung cancer deaths in men and women, respectively, making tobacco prevention and cessation essential goals for lung cancer prevention and control. Despite five decades of national and international public health accomplishments in reducing the morbidity, mortality, and economic costs of tobacco-induced diseases, there are currently an estimated 42.1 million current smokers (18.1% of all adults) in the United States alone and at least one billion smokers worldwide. Tobacco kills nearly six million people each year; more than five million of those deaths are the result of direct tobacco use, and more than 600,000 are the result of nonsmokers being exposed to secondhand smoke. Unless urgent action is taken, the annual death toll could rise to more than eight million by 2030.

Risks of Persistent Smoking and Benefits of Cessation on Lung Cancer Outcomes

Health-care providers who treat patients with cancer may assume that it is too late after diagnosis to intervene about smoking. However, an emerging body of evidence demonstrates that smoking is associated with several adverse outcomes for patients with cancer, such as increased complications from surgery, increased treatment-related toxicity, decreased treatment effectiveness, poorer quality of life, increased risk of recurrence, increased risk of second primary tumors, increased noncancer-related comorbidity and mortality, and decreased survival. Although the number of clinical studies on the effects of smoking cessation in patients with cancer is limited, the existing data suggest that many of the adverse effects of smoking can be reduced with cessation.

Although these adverse outcomes are applicable to patients diagnosed with a wide range of cancers, much of this research has focused on identifying the adverse effects of smoking for patients diagnosed with lung cancer. Continued smoking after the diagnosis of lung cancer has been associated with treatment delays and increased complications from surgery, radiotherapy, and chemotherapy. Adverse effects from continued smoking at the time of surgery include complications from general anesthesia, increased risk of severe pulmonary complications, and detrimental effects on wound healing. Complications from smoking while receiving radiotherapy include reduced treatment efficacy and increased toxicity and side effects. Smoking while receiving chemotherapy alters the metabolism of many chemotherapy drugs, decreases the effectiveness of treatment, and increases drug toxicity. Smoking cessation before lung cancer treatment reduces the risk of recurrence and the development of additional smoking-related cancers. Although further research is needed to examine the beneficial effects of smoking cessation in patients with cancer, smoking cessation after a diagnosis of lung cancer has been shown to have a beneficial effect on quality of life and performance status.

Prevalence of Persistent Smoking Among Patients With Lung Cancer

Despite these risks, at least 15.1% of all adult cancer survivors report current cigarette smoking. Patients with lung cancer tend to be motivated to quit smoking at higher rates than patients diagnosed with other cancers. Focusing exclusively on the prevalence of smoking in lung cancer, 90.2% of patients with lung cancer report ever-smoking. At the time of diagnosis, 38.7% of patients with lung cancer report current smoking, whereas 5 months after diagnosis, at least 14.2% of patients with lung cancer report current smoking. Despite heavy encouragement to quit smoking and strong intentions to quit, continued tobacco use after diagnosis and resumption of smoking after initial quit attempt remains a problem in this patient population, with an estimated 10% to 20% of all patients with lung cancer smoking at some point after diagnosis.

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