WASHINGTON, DC—At a time when more than 30 percent of all US tobacco-related deaths are due to cancer, a broad-based strategy is needed to combat tobacco use. So said speakers here at an Institute of Medicine National Cancer Policy Forum workshop. That strategy includes raising tobacco taxes; ensuring that tobacco settlement funds to states be used only for health-related projects; graphic warnings on cigarette packages; and a more aggressive role for oncologists and nurses in helping tobacco users quit.
The expectation, organizers said, is that a report from the meeting will be released by the end of the year, focusing on reducing tobacco-related cancer incidence and mortality.
In 2003, the American Society of Clinical Oncology issued a policy statement on US tobacco control, recommending that an independent commission study the tobacco problem in all its dimensions (OT, 7/10/03). The statement charged that despite the urgent public-health priority of achieving a smoke-free world, a number of tobacco control efforts have been “fragmented and incremental, leaving many important issues unaddressed.”
In the United States today, unfortunately there is “a nagging feeling that this problem [tobacco use] has somehow been solved and it's time to move on to something else,” said Howard K. Koh, MD, MPH, Assistant Secretary for Health in the US Department of Health and Human Services. But, nothing could be farther from the truth, he said. The health consequences of tobacco use continue to be a heavy and costly burden (direct medical costs due to tobacco use are about $96 billion annually).
Kenneth E. Warner, PhD, the Avedis Donabedian Distinguished University Professor of Public Health at the University of Michigan School of Public Health, provided statistics showing that currently 20 percent of Americans remain smokers; 70 percent want to quit; and 50 percent try to quit each year, but only 2.5 percent succeed. Of these, less than 10 percent are college graduates, more than 30 percent are in blue collar populations, and half have mental illness or substance abuse comorbidity, said Dr. Warner. Smoking is also on the rise among young adults as a group.
Given these statistics, there's an important role in oncology for smoking cessation, said Michael C. Fiore, MD, MPH, MBA, Director of the Center for Tobacco Research and Intervention and Professor of Medicine at the School of Medicine and Public Health, University of Wisconsin.
While they see the results of tobacco abuse, oncologists unfortunately have one of the lowest rates of tobacco assessment and counseling, he said. “With impunity, smokers come in and out of clinics today without their tobacco dependence being addressed,” he said. But, tragically, even though about 70 percent of smokers report that they want to quit, only about 25 percent of patients ever have their tobacco use assessed by a clinician.
What needs to happen is a change in the “architecture of a clinical encounter” to address each patient's tobacco use head-on, he said.
Fiore cited the US Public Health Service 2008 clinical practice guidelines for treating tobacco dependence, which it termed “a chronic disease that often requires repeated intervention.” In addition to counseling, those guidelines cite medications that are effective in helping smokers quit, including bupropion SR and varenicline and nicotine replacements: gum, inhaler, nasal spray, patch, and lozenge.
‘Tobacco Cessation Performance Measure-Set’
He also pointed to the Joint Commission's new Tobacco Cessation Performance Measure-Set (www.jointcommission.org/core_measure_sets.aspx), which took effect on January 1 of this year. That performance measure requires documented tobacco use status of all patients upon admission; evidence-based cessation counseling and medication during the hospital stay; counseling and anti-smoking medication upon discharge; and a follow-up check of tobacco-use status after discharge.
Fiore pointed out that hospitalization provides a “propitious opportunity” to assess tobacco use and recommend a smoking-cessation program, if needed. He urged clinicians to give patients the national free quit-line phone number: 1–800-QUIT-NOW.
Calling the new Joint Commission measure set “powerful,” he urged all health professionals—including oncologists—to take advantage of hospitalization as a teachable and reachable moment. Not only are many patients in the hospital because of a tobacco-caused disease such as cancer, but most US hospitals are smoke-free—which makes smoking during hospitalization very difficult for patients and can be a jump-start to cessation. Fiore urged health care professionals to make evidence-based smoking-cessation programs available in the hospital setting, which is not routinely done today.
In addition to oncologists, nurses are also effective in helping smokers quit. “Nurses can make a difference; this is absolutely within their scope of practice,” said Linda Sarna, DNSc, RN, AOCN, Professor and the Lulu Wolf Hassenplug Endowed Chair at the UCLA School of Nursing. She cited a review of 31 studies with a total of 15,205 participants that showed that compared with smokers who receive usual care, smokers who receive interventions for smoking cessation from nurses have a 28 percent greater probability of successfully quitting tobacco use for five or more months. But, she said, today “clinicians are not doing enough, not rapidly enough.”
Sarna said professional barriers to clinicians intervening to help patients stop using tobacco include: lack of awareness of the Public Health Service clinical practice guidelines; lack of awareness of the national quitline; attitudes and beliefs about the patient's willingness to quit and the duty to perform an intervention; and myths and misperceptions about tobacco dependence, including concerns about causing stigma, guilt, and stress for the patient—who is already stressed.
Other barriers include competing priorities (lack of time); lack of reimbursement; and lack of expectations on quitting by cancer centers as part of quality care after cancer diagnosis and treatment. This latter barrier is especially troubling given that that there are 12 million cancer survivors, approximately 15.5 percent of whom are current smokers, she noted.
Graham Warren, MD, PhD, Director of the Tobacco Assessment and Cessation Program at Roswell Park Cancer Institute, agreed: “Increased survivorship in cancer patients warrants preventative efforts,” he said, adding that mandatory tobacco assessment and cessation referral should be a clinical standard of care.
In cancer patients, he noted, tobacco: decreases therapeutic response; increases recurrence; increases toxicity; decreases quality of life; decreases survival; and increases the risk of a second malignancy.
Another speaker, Ellen R. Gritz, PhD, Professor and Chair of the Department of Behavioral Science and the Olla S. Stribling Distinguished Chair for Cancer Research at the University of Texas MD Anderson Cancer Center, also agreed on the importance of helping cancer survivors quit using tobacco. A member of the planning committee for the IOM tobacco meeting, she noted that the rates of current smoking among patients with lung or head and neck cancers are 40 to 60 percent, and that overall up to 30 to 50 percent of patients smoking at diagnosis do not quit, or they relapse following quit attempts.
Gritz also noted that an NCI conference on treating tobacco dependence at cancer centers in 2009 highlighted the importance of treating tobacco dependence in the context of cancer care and survivorship.
Asked by OT to comment on why tobacco use remains an entrenched public health problem (especially among those without a college degree), National Cancer Policy Forum member Otis W. Brawley, MD, Chief Medical and Scientific Officer and Executive Vice President of the American Cancer Society, said, “People with a poor education tend to smoke. Minorities tend to smoke.
“It's not just a black problem or a white problem; it's an American problem. Everybody needs to stop smoking.”