By Jacek Jassem, MD, PhD, and Carolyn Dresler, MD, MPA
Posted: August 21, 2020
The world is currently overwhelmed with cases of the novel virus COVID-19 and its devastating death toll. We acknowledge that finding a treatment, cure, and vaccine is currently our nations’ first responsibility. Amidst this, however, all of our underlying diseases continue apace—each with their own morbidity and mortality. In an effort to combat tobacco-related morbidity and mortality in lung cancer, the IASLC created the Declaration on Tobacco Cessation after a Cancer Diagnosis in early Fall of 2019—2 short months before the first case of the coronavirus exploded into the world.1 The Declaration states that the harms of continued smoking after the diagnosis of cancer are underappreciated. Smoking continuation by patients with cancer and survivors causes adverse treatment outcomes, including increased overall mortality, cancer-related mortality, and risk for second primary cancer, and it considerably increases cancer treatment toxicity.2-6 The clinical effects of smoking after the diagnosis of cancer also have a substantial effect on increased cancer treatment costs.7 Smoking cessation after the diagnosis of cancer can improve treatment outcomes, but most patients with cancer who smoke at the time of diagnosis persist in their smoking habit during treatment. An enhanced focus on smoking cessation at the time of a cancer diagnosis and active intervention may increase patients’ actions to quit.
The evidence is clear that we, as cancer care providers, must do everything to help our patients quit. Recognizing the critical importance of smoking cessation after a cancer diagnosis, the IASLC Declaration recommends implementation of the following:
- All patients with cancer should be screened for tobacco use and advised on the benefits of tobacco cessation.
- In patients who continue smoking after diagnosis of cancer, evidence-based tobacco cessation assistance should be routinely and integrally incorporated into multidisciplinary cancer care for the patients and their family members.
- Educational programs regarding cancer management should include tobacco cessation training, empathetic communication around history of tobacco use, and cessation and utilization of existing evidence-based tobacco cessation resources.
- Smoking cessation counseling and treatment should be a reimbursable service.
- Smoking status, both initially and during the study, should be a required data element for all prospective clinical studies.
- Clinical trials of patients with cancer should consider designs that could also determine the most effective tobacco cessation interventions.
The diagnosis of cancer is “the teachable moment,” allowing healthcare professionals the best opportunity to discuss with patients their nicotine addiction and shared decision-making. We must change our behavior to change our patients’ behavior.
However, as the Declaration states, most cancer care providers do not assist or refer patients for help in quitting. Indeed, surveys among ASCO members8,9 demonstrated that although most healthcare professionals recognize that smoking causes adverse outcomes, approximately 90% ask about tobacco use and 80% advise patients to quit, but few offer direct assistance with quitting. There is a clear and unmet need to address tobacco use in patients with cancer. The diagnosis of cancer is “the teachable moment,” allowing healthcare professionals the best opportunity to discuss with patients their nicotine addiction and shared decision-making. We must change our behavior to change our patients’ behavior. We must believe the science and help our patients to find quitting assistance.
One can simply provide quitting assistance in their own personal clinic, but this might be resource intensive. Rather, it is most appropriate that the hospital, cancer center, or entire clinic provide a mechanism for patients to receive tobacco cessation assistance. Because this assistance is of critical value to improved outcomes, it is essential that it is effectively provided. These services include behavioral counseling and pharmacotherapy, and they should readily be integrated into the routine patient visits in the clinic. Such assistance can additionally be amplified by telephone or online outreach.
Many of the comorbid conditions that are documented in patients with COVID-19 are overwhelmingly caused by tobacco use.
Simply, for the good of our patients with cancer, we must provide them with evidence-based tobacco cessation access. We must educate them about how important cessation is to overall health. We must assure them that cessation now is not related to the causation of their cancer; there must be no stigma associated with such insistence on cessation. But first, we, as cancer care providers, must acknowledge the importance of tobacco cessation and its effects on our patients’ outcomes, regardless of treatment plan.
We can look at the current COVID-19 pandemic and the effects that it has on everyone—particularly on those older than age 60. Many of the comorbid conditions that are documented in patients with COVID-19 are overwhelmingly caused by tobacco use. Today we need to help everyone quit tobacco, and maybe as we emerge from this pandemic, we can apply the same emphasis to our patients with cancer who have continued to smoke. ✦
About the Authors: Dr. Dresler is a retired thoracic surgical oncologist. Dr. Jassem is with the Department of Oncology and Radiotherapy, Medical University of Gdańsk, Poland.
1. Declaration from IASLC: Tobacco Cessation After Cancer Diagnosis. International Association for the Study of Lung Cancer. Published September 4, 2019. Accessed April 20, 2020. https://www.iaslc.org/About-IASLC/News-Detail/declaration-from-iaslc-tobacco-cessation-after-cancer-diagnosis.
2. Yildizeli B, Fadel E, Mussot S, et al. Morbidity, mortality, and long-term survival after sleeve lobectomy for non-small cell lung cancer. Eur J Cardiothorac Surg. 2007;31(1):95-102.
3. Vaporciyan AA, Merriman KW, Ece F, et al. Incidence of major pulmonary morbidity after pneumonectomy: association with timing of smoking cessation. Ann Thorac Surg. 2002;73(2):420-425.
4. Monson JM, Stark P, Reilly JJ, et al. Clinical Radiation Pneumonitis and Radiographic Changes After Thoracic Radiation Therapy for Lung Carcinoma. Cancer. 1998; 82(5):842-50.
5. Centers for Disease Control and Prevention. The Health Consequences of Smoking: 50 Years of Progress: A Report of the Surgeon General. Published 2014. Accessed June 16, 2020. https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf.
6. Centers for Disease Control and Prevention. Smoking Cessation: A Report of the Surgeon General. Published 2020. Accessed June 16, 2020. https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf.
7. Warren GW, Cartmell KB, Garrett-Mayer E, et al. Attributable failure of first-line cancer treatment and incremental costs associated with smoking by patients with cancer. JAMA Netw Open. 2019;2(4):e191703.
8. Warren GW, Marshall JR, Cummings M, et al. Addressing Tobacco Use in Patients With Cancer: A Survey of American Society of Clinical Oncology Members. J Oncol Pract. 2013; 9(5):258-262.
9. Warren GW, Marshall JR, Cummings M, et al. Practice Patterns and Perceptions of Th oracic Oncology Providers on Tobacco Use and Cessation in Cancer Patients. J Thorac Oncol. 2013;8(5):543-548.