While the link between quitting smoking and lower cancer risk is well-known, the link between quitting smoking and better cancer outcomes (even for patients who quit after a cancer diagnosis) is less talked about. But a growing body of research shows that patients with cancer who continue smoking during cancer treatment have poorer treatment outcomes and poorer quality of life compared with never smokers-and quitting can be beneficial. In 2017, the National Cancer Institute launched its Cancer Center Cessation Initiative, an effort to improve smoking cessation efforts in NCI-designated cancer centers. It calls for these facilities to routinely offer evidence-based smoking cessation treatment services to all cancer patients; improve electronic medical records (EMRs) to better track cessation services offered to patients and follow up to help facilitate that care; and overcome barriers to tobacco cessation efforts. To improve smoking cessation services at Sidney Kimmel Cancer Center in Philadelphia, researchers conducted qualitative one-on-one interviews with patients and clinicians. In an interview with Oncology Times, two researchers-Luke Shenton, MPH, lead author and medical student at Drexel University College of Medicine, and Ann Klassen, PhD, Member of the Cancer Prevention and Control Program of the Sidney Kimmel Cancer Center Consortium-discussed the findings and next steps of their work.
1 What are some of the biggest barriers to better tobacco cessation outcomes?
Shenton: "We used a framework to look at three different factors in smoking cessation: factors that might predispose someone to quit, enforce them quitting, and once they're in the process, factors that reinforce them continuing down that road.
"There were really big differences in opinions between patients and providers. A lot of patients report a barrier to being able to go through this process is financial. They said programs were expensive and the resources to quit (things like medications or other products) are expensive. But when you talk to providers, they categorized those things as positive enablers because these resources are free to patients. So there's a disconnect in the financial aspect in that these resources are supposed to be free, but a lot of patients don't know how to access them.
"Another big barrier we identified was time management within the oncology visit. Even though smoking cessation counseling only takes a few minutes, a clinician might only have 20 minutes for a visit with a patient, during which they also have to talk about treatments, other symptoms, surgery results, and other things.
"And, finally, there's a difference in opinion among providers about the importance of smoking cessation during cancer treatment. Everyone thinks it's important overall, but some clinicians are more of the mindset [that] the patient is here to have their cancer treated and we should probably just focus on that."
Klassen: "I think it's also maybe not widely recognized how burdensome tobacco addiction is in terms of someone's mental health. And at the same time, patients often want to take an action during cancer treatment to improve their health. There's a lot they can't control, but we find that behavior change interventions during treatment can often be therapeutic because they offer something patients can actually do.
"We sometimes look at cancer patients and think they have so much going on and they're overwhelmed, [and] we shouldn't burden them with cessation. But often, cessation is something patients appreciate being counseled on."
2 How do you think this data should inform next steps on improving tobacco cessation?
Shenton: "Moving forward, we need to do better with education. Patients need education on where they can get the right resources and the benefits of smoking cessation. And providers need education on all the ways smoking cessation can actually make a difference in the treatment process and how they can quickly use the EMR to connect patients with these services.
"The majority of providers already do have conversations about tobacco cessation with their patients, but sometimes there's a disconnect between offering the services and then following through. Currently, much of the burden of the work of quitting falls to the patient. But we know that a multidisciplinary approach is usually best. Most patients who end up quitting do so with medication, counseling, and having family members as peer support. Sidney Kimmel is already working on this in terms of updating the workflows, so that there's an opt-out rather than an opt-in strategy for tobacco cessation for patients."
Klassen: "They're working on upgrading the EMR so that information is shared more easily, so providers can better see if a patient followed up about a smoking cessation referral. Did they go once and not come back? What can the physician do when she or he sees the patient again to keep the process moving?"
3 What do you want the cancer center community to know about this work?
Klassen: "Every cancer center sits within a community and understanding what the burden of addiction is in your community, what public health partners you have in that community, [and] what the culture of tobacco use [looks like] is important. And it's really important to build a comprehensive tobacco control strategy to bring all of your inpatient, outpatient, and community services under one umbrella. I think we're moving toward a bigger public health vision of tobacco control-not just [asking if we can] get you through your surgery, but can we reduce the role of tobacco in your life, your family's life, and keep your family healthier at home?"
Shenton: "Also, it's been well-known for decades that smoking causes cancer. And a lot of people really focus on that, but then once you already have cancer, some people think it doesn't really matter anymore. But there is a growing body of literature showing the effects cessation can have during treatment-better surgical outcomes, higher survival rates of actually making it through chemotherapy, lower pain severity, and higher quality of life post-cessation."