The Oncologist, Vol. 6, No. 6, 496-505,
December 2001
© 2001 AlphaMed Press
Contemporary Perspectives in Tobacco Cessation: What Oncologists Need to Know
Cindy L. Cartera,
Janice Keyb,
Linda Marshb,
Kristi Gravesc
a Hollings Cancer Center,
b Adolescent Medicine, and
c Institute of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
Correspondence:
Cindy L. Carter, Ph.D., Hollings Cancer Center, Medical University of South Carolina, 86 Jonathan Lucas Street, Charleston, South Carolina 29425, USA. Telephone: 843-792-9192; Fax: 843-792-3200; Cartercl{at}musc.edu
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ABSTRACT
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Within the last 5 years there has been a large outgrowth of smoking cessation research, largely encouraged by the release of the 1996 Clinical Practice Guidelines for Treating Tobacco Use and Dependence. These federal guidelines published by the Agency for Healthcare Policy and Research offered comprehensive empirical evidence that tobacco cessation interventions are effective and encouraged routine implementation within medical settings. Since that time, numerous studies in tobacco cessation have augmented the state of knowledge regarding successful smoking intervention modalities. Unfortunately, approximately one-third of cancer-related deaths continue to be attributed to smoking behaviors. It is imperative that health care providers encourage and participate in the smoking cessation efforts of their patients and family members. This article provides a review of the current literature in smoking cessation and describes first-line therapies with proven effectiveness in tobacco cessation. Clinicians are encouraged to consistently screen for tobacco use and provide brief interventions utilizing behavioral counseling and pharmacotherapies to treat their patients' tobacco dependence.
Key Words. Tobacco cessation • Cancer • Smoking • Oncology
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BACKGROUND AND SIGNIFICANCE
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Smoking continues to be the number one health problem in the U.S. and the single greatest preventable cause of illness and death. One-third of all cancer deaths are attributable to smoking [1]. Almost 90% of lung and oral cancer deaths, as well as over half of all neck cancer deaths, are the direct result of tobacco use [1]. The provision of increased access to smoking cessation treatment can significantly reduce cancer risks for unaffected individuals, as well as possibly extend survival for those who already have tobacco-related disease [2].
According to Douglas B. Kamerow, M.D., director of clinical practice guidelines development at the Agency for Health Care Policy and Research (AHCPR), 70% of the 46 million adult smokers in the U.S. would like to stop smoking [3] (Fig. 1
). Research suggests that only 50% of smokers have ever been urged to quit by their doctors. The guidelines published by the AHCPR encourage physicians to motivate patients who are not yet ready to quit smoking.
For the cancer patient, continued smoking can impede the healing process following surgery and adversely affect the long road to recovery [4]. Many lung cancer patients experience guilt and remorse surrounding the cause-effect relationship of smoking and disease, yet feel unprepared to break the smoking habit during this stressful period in their lives. Family members who smoke are also impacted by the diagnosis. When faced with the reality of having a loved one diagnosed with cancer, family members, including adolescents, may be poised to respond to a program designed to help them stop smoking. Since smoking is an addiction that begins in adolescence, physicians who treat adult family members with cancer have a unique opportunity to impact the family system, including adolescent children of their patients. In fact, trends in adolescent smoking are of serious concern. Overall, the vast majority of teenagers experiment with smoking. One out of six middle school students and one out of three high school students are regular smokers [5]. This percentage is significantly higher in Caucasians than in African-American and Hispanic teens, and in boys compared with girls [6]. Despite public awareness of the health risks of smoking, the trend in adolescent smoking has demonstrated a discouraging increase in regular smoking during the 1990s, with an approximate one-third increase in frequent cigarette use between 1991 and 1999 [7]. The consequence of this increase in adolescent smoking will be an increase in adult smoking and tobacco-related illnesses, as 89% of adult smokers became addicted during adolescence [8].
Unfortunately, little progress has been made within the medical setting in promoting and providing smoking cessation interventions to adult patients and their family members. Despite proven effectiveness, many practitioners are reluctant to maintain consistent tobacco screening protocols, and fewer still actually offer assistance to their patients in their efforts to stop smoking [3]. Why do so many clinicians fail to provide smoking cessation intervention? It is likely that the reluctance to increase smoking screening and implement cessation interventions is mulitfactorial. Some possible factors include a lack of knowledge by clinicians about how to assess tobacco use and dependence quickly and consistently, limited understanding about the current state of knowledge regarding efficacy of treatment, and uncertainty about how to implement brief interventions for their patients. The purpose of the current review on tobacco research is to provide a general overview of the latest findings regarding the efficacy of smoking cessation treatment, and to guide clinicians in their efforts to screen and intervene with their patients, as well as their patient's family members who smoke.
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EFFICACY OF SMOKING CESSATION TREATMENT
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Twin studies suggest that smoking behavior and the ability to quit smoking are strongly influenced by genetics. Recent works in the genetic association for smoking hypothesize that dopaminergic genes may play an important role in the heritable influences of smoking behavior. Lerman et al. reported a significant association between polymorphisms in a dopamine transporter gene (SLC6A3-9) [9]. They found that participants with an SLC6A3-9 were less likely to be smokers than participants without allele 9 and that smokers with SLC6A3-9 genotypes began smoking later in life and had longer periods of abstinence. Sabol et al. found a significant association between SLC6A3-9 and smoking status and reported that this effect was due to cessation rather than initiation of smoking [10]. In other words, once participants became smokers, those carrying the SLC6A3-9 allele were significantly more likely to have quit smoking than those who were not carriers. This study also evaluated the role of novelty seeking, a personality trait believed to be mediated by dopamine and one found to be associated with increased risk for smoking behavior. Results of the investigation indicated that individuals with SLC6A3-9 obtained low scores for novelty seeking. Additionally, Pianezza reported that individuals with impaired functioning of enzyme CYP2A6, which helps metabolize nicotine to cotinine, are less likely to become dependent tobacco smokers [11].
Heath and Madden reported that the estimated heritability for propensity to smoke was 60% based on a meta-analytic study evaluating over 1,000 twin pairs [12]. Monozygotic twins studies have supported the hypothesis that genetic factors influence initiation and cessation of smoking. The genetic factors influencing smoking behavior are an emerging area of research currently in the early stage of development. Further research is warranted to understand the role of genetic influences on smoking behavior. Nevertheless, it appears that heritable factors may play an important role in our understanding of the risks associated with initiation and cessation of smoking.
A recent paradigm shift has reconceptualizated smoking behaviors and cessation efforts. Contemporary research in tobacco dependence supports a chronic disorder model of addiction. Individuals who attempt to stop using tobacco and fail in their attempts have often been viewed as weak or unmotivated [8]. Although maintaining a strong motivation to quit is an important factor in successful abstinence, it is rarely a sufficient condition for most successful quitters. In fact, this message has likely impeded the progress of many cessation efforts among smokers and health care providers alike, and demonstrated an unsophisticated appreciation for the nature of addiction.
Research on the biobehavioral mechanisms of tobacco dependence reveals the intensely addictive nature of nicotine. No other method delivers a faster and more efficient dose of drug to the brain than cigarettes, increasing the strong reinforcing qualities of smoking. Chronic nicotine use produces an increase in the number of brain nicotinic receptors. Although not fully understood, this increase in nicotinic receptors is believed to be the critical element in the development of tolerance and/or dependence [8]. As a result of these powerful biological and behavioral mechanisms, the vast majority of smokers do not achieve abstinence on their first attempt. Instead, most smokers experience multiple periods of abstinence and relapse before finally maintaining long-term cessation. Understanding the chronic nature of dependence is a fundamental underpinning in providing effective tobacco cessation treatment.
Much of the work evaluating changes in smoking behavior have utilized the transtheoretical model of change. This model emphasizes stages of change as the key construct in promoting health behaviors. The transtheoretical model conceptualizes change as a process involving progress through five stages: A) precontemplation; B) contemplation; C) preparation; D) action, and E) maintenance. Each stage represents ordered categories along a continuum of motivational readiness to change a problem behavior [13]. Although more research is needed to clarify the efficacy of matching smoking cessation interventions with particular stages of readiness for change, the AHCPR offers specific guidelines to help physicians motivate patients who are currently unwilling to quit with the goal of promoting their transition to a more action-oriented stage.
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EFFICACY OF CESSATION EFFORTS
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Nonprofessional modalities have traditionally been the most common form of smoking cessation efforts. The vast majority of smokers who try to quit utilize self-help methods, despite low efficacy rates. Less than 5% of self-quitters report maintaining abstinence at 1-year follow-ups [14]. Research in smoking cessation efforts confirms the need for more comprehensive smoking cessation treatment in order to significantly impact smoking abstinence rates.
Advances in smoking cessation treatment offer promising areas of development. The past 10 years have brought a dramatic increase in available pharmacological approaches to smoking cessation. Although still well below desired results, these medications, coupled with behavioral counseling, have resulted in meaningful increases in smoking abstinence rates and represent the future of tobacco cessation treatments. Currently, a number of efficacious treatments exist that can double and triple the likelihood of long-term cessation for adult smokers [15].
Health professionals can play an important role in promoting and assisting in this process of behavioral change. If physicians are encouraged to motivate their patients to quit smoking, it is essential that health care professionals ensure that mechanisms of support are in place for patients and their family members (Table 1).
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FEDERAL GUIDELINES
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In 1996, the AHCPR published the Smoking Cessation: Clinical Practice Guidelines identifying efficacious interventions for primary care clinicians and smoking cessation specialty providers [3]. These guidelines were based upon the results of meta-analyses and expert opinion regarding the state-of-the-art literature in smoking cessation. Three hundred articles met the requirements for inclusion in the meta-analysis and covered a variety of components of smoking cessation interventions including screening for tobacco use, self-help, length of treatment, group versus individual format, and type of treatment. The guidelines published by the AHCPR recommended that primary and cancer care providers implement a systematic assessment to identify all smokers.
In June 2000, updates to the 1996 guidelines were released reflecting the advances in tobacco cessation research that followed in the 4 years after the AHCPR announced their guidelines [15]. The key recommendations of the updated guidelines include:
- Tobacco dependence is a chronic condition that often requires repeated intervention.
- Because effective tobacco dependence treatments are available, every patient who uses tobacco should be offered at least one of these treatments.
- It is essential that clinicians and health care delivery systems (including administrators, insurers, and purchasers) institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in a health care setting.
- Brief tobacco dependence treatment is effective, and every patient who uses tobacco should be offered at least brief treatment.
- There is a strong dose-response relationship between the intensity of tobacco dependence counseling and its effectiveness.
- Three types of counseling and behavioral therapies were found to be especially effective and should be used with all patients attempting tobacco cessation: problem-solving/skills training, intra-treatment social support, extra-treatment social support.
- Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, they should be used with all patients attempting to quit smoking.
- Tobacco dependence treatments are both clinically effective and cost effective relative to other medical disease prevention interventions.
The updated 2000 guidelines highlight some important advances in tobacco research since 1996. Specifically, the guidelines emphasize even stronger evidence of a dose-response relationship between intensity and efficacy of treatment, as well as evidence for the efficacy of telephone counseling and other support strategies outside of the formal treatment setting. Additionally, the guideline update includes more pharmacologic treatments that have proven effectiveness as smoking cessation medications.
The involvement of physicians in smoking cessation interventions is considered crucial by the AHCPR, however, little progress has been made in the past 20 years regarding clinicians' efforts to intervene with their patients who smoke. This continues, despite a marked increase in tobacco research and evidence indicating that cessation treatments can double or triple the likelihood of long-term cessation, are appropriate for the primary care setting, and are more cost effective than many other reimbursed clinical interventions. Recent research suggests that only 15% of smokers who saw a physician in the past year were offered assistance with quitting (Fig. 2) [3]. Even among those individuals who already have cancer, quitting smoking has benefits. Smoking cessation can have a positive impact on treatment recovery and progression of further disease [16]. Cancer care physicians across the treatment spectrum, including mammography and colonoscopy, may be able to impact their patients recovery as well as reduce cancer and noncancer-related morbidity and mortality.
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Figure 2. Physician assistance with smoking cessation. Overall, half of adult smokers were encouraged to quit by their physician, including 15% who were offered assistance with quitting, but half received no intervention at all. Adapted from [2].
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SCREENING FOR TOBACCO USE
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Research investigating the use of screening within the medical setting suggests that every individual who enters the health care setting should receive an assessment of their tobacco use on each visit. Seventy percent of smokers report wanting to quit [3, 17], and are often in the contemplation stage of change. Cancer care physicians are especially poised to impact smoking behaviors in their patients and family members due to their high degree of credibility, and may be able to help smokers move to the preparation and action stages of change. However, research indicates that clinicians are not regularly assessing for tobacco use and fewer still offer specific advice on how to quit smoking.
Screening for tobacco use not only includes identifying tobacco users, but evaluating willingness to quit. As stated previously, most smokers have attempted to quit smoking on numerous occasions before successfully abstaining for long periods of time. Therefore, a conceptualization of smoking behavior change should be broad based with an emphasis on change as a "process" not an "event." Opening the discussion on tobacco use and interest in quitting is an important first step in providing brief intervention (Table 2). Each clinical contact lacking tobacco screening is a missed opportunity to facilitate the process of change for patients and their family members.
The cancer care physician can play an important role not only in the smoking cessation efforts of their patients, but also in the cessation efforts of patient's family members with whom they interact. Although most teenage smokers express a desire to quit and more than half have tried, successful cessation usually requires repeated attempts [18]. Moreover, the average age at successful cessation is about 35 years, more than 20 years after beginning smoking. Adolescent smokers are different than adult smokers in that their stage of change is more likely to be precontemplative with more rapid cycling between quit attempts and relapses [19]. The few adolescents who are able to quit (15%) are those who smoke less heavily, whose mothers encourage quitting, who are not depressed, and who see themselves as capable of quitting [20]. Support and encouragement are key elements in promoting these smoking cessation efforts among adolescents.
Other psychological factors important in smoking may vary between adolescents and adults. Adolescents are influenced by peer and family smoking status, especially parental smoking status and socialization about smoking risks [21]. Depression and stress contribute to regular smoking in adolescence [22, 23]. The belief that tobacco is "OK to use" by the adolescent subculture may counteract public health messages [24]. Concerns about weight gain, especially in college-aged girls, combined with this sense of acceptability of tobacco, increase the risk of smoking [25]. All of these psychological factors are seen in adults, however, adolescents with immature coping skills may be more vulnerable to their impact.
Despite the need for specific adolescent smoking cessation interventions, few evaluations have been conducted. A review of different treatment interventions for adolescents found overall less retention and abstinence than adult programs, however, the studies were inadequate for generalization [25, 26]. The urgent need for adolescent-targeted treatment programs has lead to recommendations from the Surgeon General for further research in this area and a national panel convened to devise an office-based brief intervention for adolescent smokers [27]. Hopefully, office-based screening of teens for tobacco use followed by a brief, effective intervention for adolescent smokers will become routine practice in primary care settings.
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CESSATION TREATMENTS
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In the past decade, pharmacological approaches to smoking cessation have improved dramatically (Table 3). The efficacy of nicotine replacement therapies (NRT) and non-nicotine medications is well established. The AHCPR encourages physicians to advise all smokers to use the nicotine patch or gum for smoking cessation, unless special circumstances prevent any nicotine use.
Nicotine replacement appears to be helpful in alleviating withdrawal and preventing short-term relapse. The transdermal patch is a convenient way to deliver nicotine directly into the system, and is available over the counter. It needs to be applied once a day and automatically delivers a standard dose of nicotine throughout the day. It has been shown to significantly increase smoking cessation rates for a diverse population of smokers. Use of the transdermal patch has been demonstrated to double cessation rates at 1 year as compared with placebo interventions. Research investigating the dose relationship of the transdermal patch with abstinence suggests that higher doses (44 mg versus 22 mg) do not enhance cessation rates.
Nicotine gum, available exclusively over the counter, is also an efficacious smoking cessation treatment offering similar results as transdermal nicotine. Unlike the transdermal patch, however, it should be noted that a review of the literature supports dose considerations. Specifically, 4 mg rather than 2 mg nicotine gum is advisable for highly dependent smokers (greater than 25 cigarettes per day). The use of nicotine spray and the nicotine inhaler are also encouraged by the AHCPR and have demonstrated effectiveness in smoking abstinence rates similar to the nicotine patch and nicotine gum, although increased side effects such as eye irritation have been noted [28].
A limited number of studies indicate that a combination of nicotine patch with nicotine gum or nicotine nasal spray is more effective than either intervention alone. However, the AHCPR points out that although combination NRT is more effective than monotherapy, the Food and Drug Administration (FDA) has not approved a combination NRT strategy for smoking cessation since no safety data exist on the use of multiple NRTs. Currently, it is recommended that combination NRT be used only for those patients who have not successfully quit smoking with the use of one NRT.
The use of non-nicotine medications has also impacted the success of smoking cessation efforts within the last 5 years. Bupropion SR is the only non-nicotine medication approved by the FDA for smoking cessation treatment and has demonstrated a doubling effect in long-term abstinence rates. In addition, Bupropion can be used with NRT and appears to increase success rates when used in combination with NRT. Its mechanism of action as a smoking cessation aid is unknown, although it is presumed to act through noradrenergic and dopaminergic mechanisms [29]. Contraindications include a seizure disorder, bulemia/anorexia, and the use of monoamine oxidase inhibitors within the last 14 days.
Bupropion and NRT are not intended to be used alone, but rather as the pharmacological component of an armamentarium involving behavioral counseling and support. In fact, the efficacy of NRT therapy and non-nicotine medications is significantly increased when used in combination with behavioral counseling. Behavioral counseling for smoking cessation generally involves problem-solving skills training and social support. Relapse prevention strategies are of particular importance since so many individuals who quit smoking have periods of relapse. Ultimately, the greater the number and intensity of smoking cessation interventions, the better. Formats such as telephone counseling support in addition to face-to-face counseling have been shown to increase efficacy rates and should be implemented into a structured counseling program or self-help intervention format whenever feasible [30]. In summary, smoking cessation interventions should take place using multiple formats and intervention strategies suggesting that physician-initiated interventions, no matter how brief, are helpful in facilitating the change process (Table 4). If possible, these screening and intervention contacts should be supplemented by more intensive behavioral counseling. No differences are evident between group and individual counseling on cessation rates [3].
Scheduled smoking is yet another approach that may be combined with behavioral counseling. Scheduled smoking interventions require the individual to smoke on a fixed time schedule that includes longer intervals between smoking over the course of time. Scheduled smoking is not to be confused with gradual tapering of smoking that many smokers utilize as a method. Gradual tapering often results in the smoker eliminating "easier" cigarettes lacking strong environmental cues. For example, a smoker may continue having a cigarette with his morning coffee and after meals but reduce smoking during other times. Scheduled smoking interventions avoid the reinforcing quality of environmental cues by requiring the individual to smoke at specific times that are not self-determined. Scheduled smoking efficacy rates appear to be similar to those found when combining behavioral counseling and NRT [3].
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SECOND-LINE PHARMACOTHERAPIES
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A number of additional medications have been investigated although not as extensively as the nicotine and non-nicotine treatments reviewed in this article. Many of these medications reportedly reduce withdrawal symptoms or provide similar effects of nicotine. According to the AHCPR guidelines, clonidine, used primarily as a hypertensive agent, has limited support as a primary or adjunctive treatment for smoking cessation, and should be used only when patients are unable to quit using other first-line medications [15]. Nortriptyline and Venlafaxine, two antidepressant medicines, currently lack outcome data to support their use as a first-line treatment for smoking cessation, however, preliminary data suggest that these medications may be helpful forms of alternative therapies for smoking cessation treatment.
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WEIGHT GAIN
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Weight gain has been cited by smokers as a factor in their reluctance to stop smoking, especially among women [3]. It is advisable to acknowledge that most people who stop smoking do experience some weight gain of varying degrees. Nevertheless, the health benefits from stopping smoking exceed the health risks associated with increased weight gain. Research in weight gain associated with smoking cessation has supported gender and ethnic differences in attitudes and behaviors surrounding smoking cessation. Overall, women and African-Americans (who smoke heavily) are at increased risk for greater weight gain [3]. Women report that weight gain concerns are important factors in the initiation and/or maintenance of smoking habits [3]. Clinical guidelines recommend that clinicians encourage patients who are making a quit attempt to focus on their cessation efforts and achieve increased levels of confidence in their abstinence before addressing weight-gain issues.
A patient who is adequately prepared for the possibility of weight gain may be more likely to incorporate a moderate level of exercise into their smoking cessation efforts, a strategy that has been found to reduce the amount of post-cessation weight gain (Table 5).
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RECOMMENDATIONS TO CANCER CARE PROFESSIONALS
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The recent settlements with large tobacco manufacturers have resulted in a number of policy changes in how tobacco is marketed and advertised to the public. In addition, federal funding for tobacco research has been dramatically increased, and will likely spurn additional developments in pharmacological treatments of tobacco cessation. These trends represent a fertile climate for promoting more aggressive participation by health care providers in the cessation efforts of their patients.
Currently, there exist a number of efficacious smoking cessation interventions available to smokers who want to quit. It is imperative that clinicians routinely screen for tobacco use and assist in their patients' efforts to stop smoking (Table 6). Although a dose-intensity relationship for behavioral counseling has been supported in the literature, even brief interventions increase abstinence rates (Tables 4-6
).
Overall, progress has been made in understanding the nature of tobacco dependence and cessation treatment. Based upon our current state of knowledge, it is important to approach smoking cessation from a broad perspective, emphasizing the chronic nature of addictions. A key feature of this model is that opportunities for intervention occur at multiple levels and include repeated encouragement and assistance. Every patient who smokes should be offered some level of treatment, no matter how brief.
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Received February 9, 2001;
accepted for publication September 17, 2001.
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Abstract
Background and Significance
