Are You Talking to Patients About Smoking Cessation?

Despite aggressive campaigns to educate Americans on the lifethreatening risks of smoking, nearly 500,000 people die each year in the United States from smoking-related illness, according to a recent study in Epidemiology. Even patients with smoking- related cancers have trouble quitting, with about two-thirds of patients with lung cancer continuing to smoke.

At the annual meeting of the Hematology/Oncology Pharmacy Association, Jane Pruemer, PharmD, BCOP, FASHP, professor of clinical pharmacy practice at the University of Cincinnati’s James L. Winkle College of Pharmacy in Ohio, suggested clinicians have an obligation to encourage patients with cancer who smoke to give up the habit. “It is inconsistent to provide health care and, at the same time, remain silent about a major health risk,” she said. Studies show intervention from a clinician nearly doubles the chances of a patient succeeding in his or her attempt to quit smoking compared with pharmacologic interventions alone or self-help materials.

Although medical oncologists often tell smokers they should quit, Pruemer said they do not always explain why. “Patients may think, ‘I’ve already got cancer, what’s the reason to quit?’” She rattled off several: Smoking and nicotine exposure decrease the effectiveness of certain anticancer therapies, particularly erlotinib (Erbitux); tobacco use impairs wound healing after surgery and increases the risk of infection; and for patients receiving radiotherapy, smoking is associated with greater epithelial damage in irradiated tissue and a higher incidence of mucositis. Perhaps the most important reason to quit is that patients who continue smoking have a higher risk of second cancers, shorter survival, and worse quality of life.

The first step in getting a patient to quit is finding out how much they smoke, which is not always easy. “Do you know that 1 in 6 smokers really doesn’t tell the truth about how much they smoke?” Pruemer asked. Healthcare providers need to be understanding when patients seem reluctant to discuss their tobacco use. Pruemer recommended highlighting the link between smoking and their cancer to motivate them to take the next steps. “If you don’t have a [tobacco cessation] program, refer them to one you know about. They are out there.”

A successful program addresses the physiological and behavioral aspects of dependence. “These two have to work together. ...We can’t just hand the patient a box of patches and expect them to be able to quit,” said Pruemer. People highly dependent on cigarettes find it harder to quit. This includes someone who smokes >1 pack a day or who lights up within 30 minutes of waking. People with psychiatric disorders or a history of chemical dependency also struggle. Some patients are convinced that cigarettes have positive effects, like keeping them calm or preventing weight gain. Pruemer said clinicians must dispel these myths and describe how cigarettes operate on them physiologically. Another component of behavioral modification is identifying their smoking triggers. “Make sure they understand the difference between a physical craving and habit.”

Before selecting a pharmacologic aid, Pruemer recommended working with the patient to establish their goals, such as relieving withdrawal symptoms, controlling urges, and abstinence. Most patients have tried quitting before, so she recommended finding out what worked and what did not work in those attempts. The pharmacologic options are essentially equal in effectiveness, and which one to use is primarily a matter of preference.

Nicotine replacement therapy (NRT) comes in various forms and is a popular in patients with underlying cardiovascular disease. Pruemer said the standard dose might not work for heavier smokers. “I have a lot of patients that come in and they smoke 3 or 4 packs a day—I had a lady who smoked 5 packs a day. If you give them the equivalent of 1 pack of nicotine, they’re not going to quit,” she explained. A Mayo Clinic study in 1995 demonstrated higher quit rates at end points of 8 weeks, 6 months, and 1 year in patients using a 44-mg patch compared with the 11-mg or 22-mg patches. Although researchers have not found an increase in adverse effects when using the dose equivalent of 2 patches, Pruemer said, “I would not do this unless patients are under the guidance of a physician that you’re working with.”

Prescription options consist of bupropion SR (Zyban) and varenicline. “Bupropion works by increasing the central nervous system levels of dopamine, which makes patients feel better.” The drug is started 1 week prior to the scheduled quit date. Patients take 150 mg once daily for 3 days and then increase to twice-daily dosing for the remaining 7 to 10 weeks of therapy. The drug increases the risk of seizures, and Pruemer advised extreme caution for patients with a history of brain surgery or trauma, patients taking medications that increase seizure risk, and patients with severe cirrhosis. Bupropion is contraindicated in patients with bulimia, anorexia nervosa, or seizure disorders, and in those who are abruptly quitting alcohol or sedatives.

Varenicline binds to nicotine receptors, blocking the usual dopaminergic boost patients get from smoking. It also helps alleviate withdrawal symptoms. As with bupropion, patients should start the drug 1 week prior to their quit date; it should be taken with food. The dose is titrated to 1 mg twice daily by the start of the second week. This dosing is continued for 10 weeks. Pruemer cautioned that varenicline increases the risk of depression.

Patients unable to quit on a singleagent option might be candidates for therapy that combines NRT agents or uses an NRT agent with bupropion. Varenicline should not be used as part of a combination regimen. Another option is to continue on pharmacologic therapy beyond the standard treatment period.

During the question and answer session, Pruemer was asked whether patients with rapidly progressive disease or in palliative care should quit. “Even those patients are going to have a higher risk of pneumonia and more complications at the end of life, and their quality of life is going to be poorer. There’s plenty of data that still recommends they should be quitting,” she responded.

The benefits of smoking cessation are immediate and long-term for patients with cancer, and Pruemer said, “It can be one of the single most effective strategies to improve outcomes for our patients.” Individuals who work at places that do not offer smoking cessation programs can still help their patients who smoke by initiating the conversation and then referring them to an established program.