Smoking Cessation for Cancer Prevention

Kristy Murphy, MS, CTTS, NCTTP

Cigarette smoking is the chief, single, avoidable cause of death in our society and the most important public health issue of our time.”

--C. Everett Koop, M.D., former U.S. Surgeon General

Disclosure

I have no conflict of interest to disclose.

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Objectives

Examine the value of smoking cessation counseling to aid

in cancer prevention.

Illustrate the need for medication management in addition

to individual and group counseling.

Provide Motivational Interviewing techniques that can

make it easier and more effective to talk to patients about

quitting smoking.

Programs available for referrals

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Indiana

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The latest CDC data shows that Indiana’s 2017

smoking rate was 21.8%, the 7th highest for

adult smoking in the U.S.

22% 14%

Marion

County,

21%

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

https://www.countyhealthrankings.org/app/indiana/2017/rankings/marion/county/outcomes/overall/snapshot

Medical Complications

• 40% of all cancers diagnosed in the U.S. are linked to tobacco use, and smoking

is responsible for 30% of cancer deaths.

• About 15% of smokers will develop lung cancer; the leading cause of cancer

death in both men and women, and smoking is linked to 80-90% of those cases.

• Smoking contributes to Heart Disease-the leading cause of death to men and

women in the US

• 10% of all cardiovascular deaths are from smoking

• 20% of smokers will develop COPD – the 3rd leading cause of death in USA

• 90% of patients diagnosed are current or former smokers

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Cancers Caused by Tobacco Use

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Pack Years for Former Smokers

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When looking at lung cancer risk, the calculation of pack years is equally

important for former smokers.

• The risk of lung cancer remains high for an extended period of time after quitting

smoking, and former smokers may still be at risk decades after quitting.

• Roughly 80% of people who develop lung cancer today are non-smokers.

• If around 10-20% of lung cancers occur in people who have never smoked

• This means the largest group of people diagnosed with lung cancer today are former

smokers.

• The Framingham Heart Study (2018) found that roughly 40% of lung cancer

occurred in people who had quit smoking more than 15 years before their

diagnosis.

Benefits of CT Scans

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CT screening should be recommended for:

• All current and former smokers aged 55-74

• 30 pack-years or more

• who have quit less than 15-years ago.

Cancer mortality rate could be cut by 20%

Cessation Benefits Even After Cancer

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• Improved outcomes/effectiveness for all treatment, including chemotherapy,

radiation therapy, and surgical procedures

• Reduced risk of death from cancer

• Cancer survival rates increased

• Reduced rate of secondary cancer diagnosis

Why can’t my patients quit?

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• The “hardening hypothesis?”

• Co-occurring mental illnesses or addictions.

• Misinformation.

• Lack of support.

• Lack of motivation.

• Don’t know where to start.

• Lack of coping skills.

The Three Components of Smoking

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Physical Dependence: need for nicotine (unpleasant withdrawal symptoms when

you quit)

Psychological Dependence: habit, comfort, emotions, stress relief. (hard to stay

away from nicotine when you quit)

Social Dependence: smoking environments, places you smoke (favorite chair),

people you hang around or talk to on the phone.

We must deal with both physical and mental aspects to

help them quit and STAY quit!

Physical Dependence

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Pharmacotherapy

First Line medications available over the counter:• Nicotine gum

• Nicotine patches

• Nicotine lozenge

Prescription only:• Nicotine nasal spray

• Nicotine inhaler

• Bupropion (Wellbutrin)

• Varenicline (Chantix)

Indiana’s New Law

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As of August 1st, 2019, anyone on commercial insurance or Medicaid can now

purchase all tobacco cessation products, including Chantix and Zyban without a

prescription.

• Just went into effect, many pharmacies are not even aware

• Indiana is still working through how this process will work here (there are only

11 other states who have implemented this change.)

• Still not sure what this means for private insurance or uninsured.

• Still beneficial to write prescriptions

Nicotine Replacement Therapy

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Medications

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Bupropion SR 150

• Start 1-2 weeks before quit

date

• Doubles chance of success

over placebo

• Best if combined with NRT

• Very affordable

Varenicline

• Reduce to Quit guidelines

– Allows patients to smoke

longer before setting a quit

date.

– Cut in half by end of first

month, set quit date by end

of second month

– Nausea often due to patients

not eating breakfast or taking

with coffee

• Highest success rate

❖ 2016 research study indicated high degree of safety in both

medications against neuropsychiatric adverse events

Psychological Dependence

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This is part of the behavior, the reasons why people use tobacco.

–Stimulation

–Pleasure

–Handling

–Relaxation/Tension Reduction

–Craving

–Habit

Making a quit plan can really help!

Social Dependence

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“Why won’t my patient quit already?”

Quitting smoking is incredibly hard. Most smokers have 44 different

triggers and rituals including smoking in the following situations:

Behavioral counseling can help patients manage triggers.

A Multi-Faceted Approach

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• My patient is already interested in using cessation

products/medications. Is there any benefit for them to have individual

and group counseling for tobacco cessation?

• I already hand out information on tobacco use, isn’t this enough?

Number of sessions

Estimated quit rate*

0 to 1 12.4%

2 to 3 16.3%

4 to 8 20.9%

More than 8 24.7%

UCSF (2016). RX for Change: Assisting Patient with Quitting. Retrieved from

http://rxforchange.ucsf.edu/curricula/teaching_materials.php

What about E-cigs/vaping?

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Harm Reduction versus Harm Elimination

May be safer than smoking tobacco

• Fewer known carcinogens and

chemical compounds

• No burning of tobacco and high-

heat combustion

• Long-term health effects data

not yet available

• Not approved as a cessation aid

Not a safe alternative to smoking

• 10 identified carcinogens, found in

higher concentrations

• VOC’s

• Propylene glycol

• Heavy Metals (nickel, tin, lead)

• Lipoid pneumonia and “popcorn lung”

• E-juice shown to restrict blood

vessels when inhaled

• Higher nicotine content (inaccurate

labeling)

• Acute Respiratory Distress Syndrome

of 2019.

What about E-cigs/vaping?

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Acute Respiratory Distress Syndrome (2019):

• As of September 11th, 380 confirmed vaping-related illnesses

• 36 states & US Virgin Islands

• Six deaths confirmed

• No identified device or product linked to all cases

• FDA is analyzing nicotine, THC, other cannabinoids, “cutting agents,”

other additives, pesticides, opioids, poisons and toxins.

• Potential lead, Vitamin E acetate

• Be sure to ask patients if they have vaped marijuana if

experiencing acute respiratory symptoms

Youth and Young Adult E-cigs/vaping Use

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• According to findings from the University of Michigan’s 2018

Monitoring the Future (MTF), there are 1.3 million new adolescent

nicotine vapers in 2018, as compared to 2017.

• Largest ever recorded 1-year increase in substance use for 10th and

12th grade students in the U.S.

• One in five 12th graders vaped nicotine in the last 30 days and 37%

reported any vaping in 2018.

• Marijuana vaping also rose in 2018 among all grades

• According to a CDC report, tobacco use is also on the rise among US

youth, driven by the popularity of E-cigarettes. Nearly 5 million

students (more than 1 in 4 high schoolers and about 1 in 14 middle

schoolers) reported using tobacco in the last 30 days.

Youth and Young Adult E-cigs/vaping Use

22https://www.cdc.gov/vitalsigns/youth-tobacco-use/index.html

Tips for Talking with Patients

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Barzilai et al. (2001). Prev Med 33:595–599; Conroy et al. (2005). Nicotine Tob Res 7 Suppl

1:S29–S34.

UCSF (2016). RX for Change: Assisting Patient with Quitting. Retrieved from

http://rxforchange.ucsf.edu/curricula/teaching_materials.php

Tips for Talking with Patients

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Tobacco users expect to be encouraged to quit by health professionals.

Giving advice or making suggestions is likely to elicit pushback from

clients (Miller & Rollnick, 2013).

A good method to try during brief interventions is the EPE method of

Motivational Interviewing:

• Elicit

• Provide

• Elicit

Objective: to maintain the dialogue driven approach of MI, in order to

gauge first the patient’s existing knowledge, and then their thoughts on the

information you provide.

EPE

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Examples of questions include:

• “What do you already know about?”

• “What would you like to know about?”

• “May I share some information with you about?”

Elicit

• Assess their knowledge

• Interest in quitting

• Permission to give advice

Provide

• Affirmation

• Relevant advice and information

Elicit

• Their thoughts

• Questions or concerns

• Next steps

Example of EPE in Action

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Patient: I have this really bad cough that won’t go away. I am sure

that it doesn’t help that I keep smoking, but it is so hard to quit.

Provider: What strategies have you tried to help you quit? (Elicit)

Patient: I just tried going “cold turkey,” but I didn’t make it very long.

Provider: Would it be okay if I told you about some medications that

can really help with your cravings? (Seeking Permission)

Patient: Sure, if you think it would help.

Provider: A lot of my patients really like….what do you think about

that? (Provide-Elicit)

If your patient is not quite ready to quit…

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That’s OK! Making small changes now can help them

succeed down the road.

• Suggest reducing down to 1 pack per day

• Set smoking limits

• No night smoking

• No binge smoking

• Refer to a program if interested

What programs are available in Indiana?

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Quit Now Indiana(Indiana Tobacco Quitline)

Freedom from Smoking (FFS) Aspire Tobacco Free Program

Type of ProgramTelephone coaching, web coaching,

text supportGroup class, telephone, web-based,

workbookComprehensive; 1-on-1 coaching, group

support, relapse prevention

Success Rates at 1 month

unknown unknown 68.4%

Success Rates at 3 month

unknown 28.8% 55.6%

Success Rates at 6 month

unknown unknown 37.4%

Success Rates at 12 month

unknown 16.3% 21.9%

*FFS- 3 month and 12 month quit rates are based upon abstinence for the past 90 days at time of reporting

IN.gov. (2016). Welcome to Indiana Tobacco Quitline. Retrieved from http://www.in.gov/quitline/index.htm

Quit Now Indiana. (2002). Quitapedia. Retrieved from http://www.quitnowindiana.com/Quitapedia.html

Thieleke et al. (2005). An evaluation of the Freedom From Smoking Online cessation program among Wisconsin residents. WMJ, 104(4): 41-4.

American Lung Association. (2016). About Freedom From Smoking. Retrieved from http://www.lung.org/stop-smoking/join-freedom-from-

smoking/about-freedom-from-smoking.html

What Can You Start Doing Tomorrow?

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Quick and easy:

•Get the conversation started!–Talk about tobacco use with all patients

•Make brief interventions routine–Encourage patients to make a commitment to a tobacco-free life

•Refer to available resources for further counseling

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References

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• American Cancer Society. (2014). When smokers quit – what are the benefits over time? Retrieved from

http://www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide-to-quitting-smoking-benefits

• American Cancer Society (2019). What Do We Know About E-Cigarettes? Retrieved from https://www.cancer.org/cancer/cancer-causes/tobacco-

and-cancer/e-cigarettes.html

• American Lung Association. (2016). About Freedom From Smoking. Retrieved from http://www.lung.org/stop-smoking/join-freedom-from-

smoking/about-freedom-from-smoking.html

• Anthenelli, Benowitz et al. (2016). Neuropsychiatric safety of smoking cessation meds. Lancet, ePub 2016 Apr 22.

• Barzilai et al. (2001). Prev Med 33:595–599; Conroy et al. (2005). Nicotine Tob Res 7 Suppl 1:S29–S34.

• Cataldo, et al. (2010). Smoking Cessation: An Integral Part of Lung Cancer Treatment. Oncology. 78: 289-301.

• Centers for Disease Control and Prevention (2017). Current cigarette smoking among adults in the United States. Retrieved from

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/#states

• Centers for Disease Control and Prevention (2016). Cancers linked to tobacco use make up 40% of all cancers diagnosed in the United States

[Press Release]. Retrieved from https://www.cdc.gov/media/releases/2016/p1110-vital-signs-cancer-tobacco.html

• Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008

• https://www.countyhealthrankings.org/app/indiana/2017/rankings/marion/county/outcomes/overall/snapshot

• E-cigarettes and Lung Health. (2015). Retrieved from http://www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health.html

• Elridge, Lynne MD. (2019). Pack Years of Smoking and Lung Cancer Risk. Retrieved from https://www.verywellhealth.com/definition-of-pack-years-

of-smoking-2249140

• Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

• Indiana State Department of Health. (2019, July 15). Gov. Halcomb Directs Actions Aimed at Reducing Indiana’s Smoking Rate [Press Release].

Retrieved from https://calendar.in.gov/site/isdh/event/gov-holcomb-directs-actions-aimed-at-reducing-indianas-smoking-rate/

• IN.gov. (2016). Welcome to Indiana Tobacco Quitline. Retrieved from http://www.in.gov/quitline/index.htm

• Miech, R. A., Schulenberg, J. E., Johnston, L. D., Bachman, J. G., O'Malley, P. M., & Patrick, M. E. (2018, December 17). National press release,

"National Adolescent Drug Trends in 2018." Monitoring the Future: Ann Arbor, MI.

• Miller, W. R. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (3rd Ed.). Guilford Press: New York.

• Miller, W. R. & Moyers, T. B. (2015). The forest and the trees: Relational and specific factors in addiction treatment. Addiction, 110 (3), pp. 401-‐413.

• Rudavsky, Sheri (2019, July 15). For smokers trying to quit, Chantix, Zyban will no longer require a prescription. Indianapolis Star. Retrieved from

https://www.indystar.com/story/news/health/2019/07/15/state-aims-make-easier-pregnant-women-stop-smoking/1717459001/

• Sanford NN, Sher DJ, Xu X, Aizer AA, Mahal BA. Trends in Smoking and e-Cigarette Use Among US Patients With Cancer, 2014-2017. JAMA

Oncol. Published online February 14, 20195(3):426–428. doi:10.1001/jamaoncol.2018.685

• Singh, Arrazola et al. (2016). Tobacco use among high school students in the US. MMWR, ePub 2016 Apr 15.

• Thieleke et al. (2005). An evaluation of the Freedom From Smoking Online cessation program among Wisconsin residents. WMJ, 104(4): 41-4.

• UCSF (2016). RX for Change: Assisting Patient with Quitting. Retrieved from http://rxforchange.ucsf.edu/curricula/teaching_materials.php

• U.S. Dept of Health and Human Services, June 2000

• USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS

• USDHHS, (2012) Report of the Surgeon Genera

• USPHS Clinical Practice Guidelines

• Quit Now Indiana. (2002). Quitapedia. Retrieved from http://www.quitnowindiana.com/Quitapedia.html

• Wyatt, J. and Singer, A. (2016). Clinical Conversations about Cannabis: Using Elicit-Provide-Elicit. Retrieved from https://hecaod.osu.edu/clinical-

conversations-about-cannabis-using-elicit-provide-elicit/