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Approximately one in six American adults is a current smoker.
Smoking accounts for one-third of all cancer deaths.
In general, patients with cancer have a higher dependence on nicotine and are more likely to be smokers or ex-smokers.
Approximately 15.1% of adult cancer survivors are current smokers.
The reward pathway and dopamine are involved in the use and abuse of and dependence on all such substances, including nicotine.
Pharmacogenetics research has the premise to tailor treatment to enhance efficacy and reduce toxicity.
Several instruments measure nicotine dependence among cigarette smokers; among them are the Fagerström Test for Nicotine Dependence (FTND) and Heaviness of Smoking Index (HSI). However, the evaluation and final recommendation are clinical, and the treatment plan must be individualized.
Nonpharmacologic treatments include behavioral counseling (e.g., identifying triggers and managing withdrawal), quitlines, and self-help material (e.g., booklets and videos).
Nonpharmacologic approaches are popular but yield relatively low quit rates if used alone.
Pharmacologic treatments approved by the US Food and Drug Administration, including nicotine replacement therapies (e.g., transdermal patch, gum, nasal spray, inhaler, and lozenge) and bupropion, have been shown to double smoking cessation rates compared with placebo. Varenicline has efficacy superior to that of nicotine replacement therapies and bupropion.
About half of patients with cancer continue to smoke after diagnosis, even though tobacco use complicates cancer treatment, reduces survivorship rates, increases the risk for a second primary tumor, and diminishes quality of life.
Few studies have examined predictors of continued smoking among patients with cancer, but some studies have reported on such factors as nonsmoking-related cancers, comorbid depression, and poor prognosis.
Several retrospective studies have shown the detrimental effect of continuing to smoke on cancer treatment outcomes. A limited number of randomized controlled trials of smoking cessation treatments have been conducted among patients with cancer. These reports suggest that a combination of medications and a behavioral approach are needed to make a difference.
Patients with cancer who use tobacco should be treated according to evidence-based treatment guidelines, with particular attention paid to tailoring education about their disease-tobacco link, pharmacotherapy, comorbid medical and psychiatric disorders, and family and household tobacco use.
Health care providers have limited time and expertise to address smoking among patients with cancer, and patients may have comorbid substance use or dependence or other emotional and mental disorders that undermine their ability to quit smoking.
Systems-level changes and tailored treatment approaches are needed to identify all tobacco users, lower the rate of persistent tobacco use, and reduce recidivism among patients with cancer.
Tobacco use has become a worldwide epidemic, and cigarettes are the most common form of tobacco consumed. Smoking results in some of the deadliest yet most preventable diseases, such as respiratory diseases, cardiovascular diseases, and cancer. Tobacco use accounts for at least 30% of all cancer deaths in the United States, and smoking has been causally linked to 18 different cancers, including lung, head and neck, esophageal, pancreatic, bladder, kidney, cervical, endometrial, and gastric cancers and acute myeloid leukemia. The scare of a diagnosis of cancer often impels smokers to quit, and although some people resume use of tobacco once their cancer is in remission, others manage to avoid a relapse.
The high recidivism rates could be attributed to comorbid conditions and to the neurobiology of tobacco addiction. Tobacco addiction is a complex phenomenon. Nicotine receptors are spread throughout most areas of the brain, and nicotine consumption activates the reward pathway, as do all other substances of addiction. In addition, several other neurotransmitter systems are implicated in the process of establishing an addiction to nicotine. After years of tobacco consumption, complex neuronal involvements and adaptations develop, rendering the extinguishing of tobacco addiction a challenging task. However, pharmacologic and behavioral treatments have proven to be essential and highly effective in comparison with other medical treatments of chronic diseases. In recent years, individualized treatment has become the gold standard, with hopes that advancement in genetics will allow us to eventually match the best treatment to each individual profile. Unfortunately, multiple hurdles and obstacles remain in extending basic treatment to all smokers and tobacco users, including those diagnosed with cancer and cancer survivors. This chapter summarizes these aspects of tobacco use disorder and their implication for patients with cancer. For the purpose of this chapter, the newer term tobacco use disorder is used interchangeably with older ones such as nicotine dependence (ND) and tobacco addiction.
Tobacco use, in particular smoking cigarettes, began an upward trend around the beginning of the 20th century. This trend has been mostly attributed to James Buchanan “Buck” Duke, who introduced the mechanized manufacturing of cigarettes and used aggressive marketing techniques, in addition to other societal forces and circumstances such as the free cigarettes provided with daily rations to all enlisted American soldiers during World Wars I and II. That upward trend continued until a pivotal moment: the release of the landmark first Surgeon General's report on smoking and health in 1964, at which point the evidence from more than 7000 scientific publications on harm from tobacco smoke was put together and received the endorsement of Surgeon General Luther Terry, the highest officer for public health within the US government. That report had an enduring effect on public beliefs and attitudes about tobacco. As an example, a Gallup survey conducted in 1958 found that only 44% of Americans believed smoking caused cancer, whereas 70% believed so by 1969, 5 years after the report was published. The belief that smoking causes cancer continued to rise, and the rate of belief reached 94% by 1990. Furthermore, since 1964 a gradual and almost annual decrease in smoking rates has occurred in the United States, with the rate reaching 15.2% in 2015. This lower rate nonetheless encompasses 45 million Americans who, more than 50 years after the landmark report, continue to use tobacco despite the clear knowledge of harm from its consumption. Other Surgeon General reports subsequently solidified the case against tobacco consumption, and to date 37 of those reports have been dedicated to tobacco (most recently the 50th anniversary report ), focusing on specific topics such as nicotine addiction, secondhand smoke, minorities, women, and youth. Although these efforts have improved public health, disparities in health care unfortunately extend to tobacco consumption, as evidenced by higher smoking rates among American Indians/Alaskan Natives, persons with a diagnosis of mental health or substance use disorders, those who are under the poverty level of income, and the unemployed. It is of importance to note that level of education is inversely related to smoking rates.
Although the trend for smoking among patients older than 45 years who are recovering from cancer has decreased to about the same as for the general population, the prevalence among survivors in the younger age group is still high. Around 40.4% of persons 18 to 44 years of age in the cancer survivors cohort still smoke cigarettes, compared with 24.4% of persons 18 to 24 and 24.1% of persons 25 to 44 years of age in the general population. Nevertheless, one potential confounding factor contributing to these statistics is the high mortality rate in patients with smoking-related tumors. Therefore smokers who would survive less lethal cancers are counted within the younger age group.
Smoking cessation rates in the cancer population seem highly dependent on the disease (tumor) site and its relationship to smoking. As an example, around 80% of patients with lung cancer and 65% of patients with head and neck cancer were reported to have stopped smoking in the year after their treatment compared with 31% of patients with bladder cancer. Other factors increase the likelihood of smoking cessation among patients with cancer, including having a good prognosis, having spent a long time in the hospital (a smoke-free environment), and having treatment-related adverse effects. In particular, adverse effects of treatment such as nausea, difficulty breathing, facial surgery, or difficulty swallowing may make it harder or more difficult to smoke. Consequently, physicians should pay attention to the particular smoking-cessation pattern in patients with cancer. Typically, cancer survivors have an increased chance of a delayed relapse to smoking 1 to 6 months after treatment, in contrast to persons in the general population, who generally relapse within the first week or so of cessation. Unfortunately, it has been reported that some patients with lung cancer who have already abstained from smoking before their diagnosis tend to return to smoking once they are informed of their cancer. Many studies have been published on the benefits of smoking cessation in patients with cancer, with many focusing on cancer treatment–related outcomes ( Table 24.1 ). Unfortunately, almost all published studies to that effect have methodological limitations, such as use of retrospective analyses, nonstandardized tobacco assessment, no biochemical confirmation, and no tracking of behavior after diagnosis. Addressing smoking behavior at the time of diagnosis and throughout treatment and recovery is thus essential for persons with cancer, constituting a continuum of potential teachable moments (i.e., health events that might motivate individuals to adopt risk-reducing behaviors).
Authors (Journal) | Year | Cancer Outcome if Continued Smoking | Sample Size | Tumor Site |
---|---|---|---|---|
Fortin et al (Int J Radiat Oncol Biol Phys) | 2009 | Smoking and drinking at baseline were associated with poor outcomes | 1871 | Head and neck |
Rades et al (Int J Radiat Oncol Biol Phys) | 2008 | Smoking during radiation had a significant effect on locoregional control | 181 | Lung |
Marin et al (Plast Reconstr Surg) | 2008 | Serum cotinine concentration greater than 10 ng/mL may predict an increased risk of wound complication | 89 | Head and neck |
Chen et al (BJU Int) | 2007 | Higher recurrence rate for patients with non–muscle-invasive bladder cancer | 297 | Bladder |
Tammemagi et al (Chest) | 2004 | Worse survival in smokers | 1155 | Lung |
Garces et al (Chest) | 2004 | Smoking after a lung cancer diagnosis negatively affects quality-of-life scores | 1506 | Lung |
Pytynia et al (J Clin Oncol) | 2004 | Threefold increases in risk for overall death, death as a result of disease, and recurrence of disease | 100 | Head and neck |
Fox et al (Lung Cancer) | 2004 | Poorer prognosis for survival after radiation therapy of non–small cell cancer | 237 | Lung |
Nordquist et al (Chest) | 2004 | Worse survival | 654 | Lung |
Videtic et al (J Clin Oncol) | 2003 | Poor survival rates if patients continued to smoke during radiation and chemotherapy | 215 | Lung |
Chelghoum et al (Ann Oncol) | 2002 | Lower survival in patients with acute myeloid leukemia by shortening complete remission duration and subsequent survival; severe infections during aplasia | 643 | Leukemia |
Kreuzer et al (Br J Cancer) | 2000 | Higher risk of developing lung cancer among men than among women | 9792 | Lung |
Marshak et al (Int J Radiat Oncol Biol Phys) | 1999 | Smoking correlated with decreased local control | 207 | Glottis |
Fleshner et al (Cancer) | 1999 | Diminished recurrence-free survival | 286 | Bladder |
Daniell et al (J Urol) | 1995 | Greater 5-yr tumor-specific mortality rate with stage D2 disease | 359 | Prostate |
Daniell et al (Am J Clin Pathol) | 1993 | More often advanced-stage disease (stages II–IV) | 157 | Endometrium |
Risch et al (Am J Epidemiol) | 1993 | In both sexes, a greatly elevated risk of developing lung cancer, and an appreciably stronger risk for females than for males | 845 | Lung |
Rugg et al (Br J Radiol) | 1990 | A highly significant correlation of cancer during and/or after treatment | 41 | Head and neck |
Archimbaud et al (Cancer) | 1989 | Associated with early blast crisis and short survival | 173 | Leukemia |
Daniell (Cancer) | 1988 | Tobacco and obesity potentiate the early spread of malignant disease | 623 | Breast |
Daniell (Cancer) | 1986 | More advanced stage of tumors | 392 | Colon |
Phillips et al (Cancer) | 1985 | Marked depression in natural killer activity that was comparable with that of patients with carcinoma of the lung | 68 | Breast |
Stevens et al (Arch Otolaryngol) | 1983 | Smoking after diagnosis had a fourfold increase in the recurrence rate | 200 | Head and neck |
Daniell (N Engl J Med) | 1980 | Fared less well than nonsmokers with breast cancer | 78 | Breast |
Hinds et al (J Natl Cancer Inst) | 1982 | Greater probability of dying during the 12 mo after diagnosis | 223 | Lung |
Johnston-Early et al (JAMA) | 1980 | Decreased survival | 112 | Lung |
Another opportunity for teachable moments arises during lung cancer screening using low-dose computed tomography (LDCT). The US Preventive Services Task Force recommends LDCT screening in individuals 55 to 80 years old with a 30 pack-year smoking history who currently smoke or who have quit within the past 15 years. A systematic review of two randomized controlled trials (RCTs) and three observational studies found that although LDCT itself does not influence smoking behavior, positive results (i.e., finding a nodule or a tumor) were associated with increased abstinence. A more recent analysis of 18,840 current and former smokers from the National Lung Screening Trial found that false-positive screening results were associated with modest increases in abstinence among smokers over the course of a 5-year follow-up period. These studies have similar limitations to other studies about smoking cessation in cancer patients, including nonstandardized assessment of smoking behavior and no biochemical verification of abstinence. Therefore more research is needed on the effectiveness of lung cancer screening as a teachable moment for smoking cessation. It will also be important to study the effectiveness of offering evidence-based smoking cessation interventions at the time of lung cancer screening, which have the potential to further motivate smokers to quit beyond lung cancer screening itself.
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