The current state of our nation has resulted in an ever-present focus on the COVID-19 virus. This is fully warranted given its indescribable impact on the psychological, emotional, and financial well-being of individuals and communities worldwide. As our society tunes in daily to a barrage of pandemic casualty data, a number of smokers have expressed increased interest in assistance with smoking cessation. This observation of increased “readiness to quit” is likely influenced by reports concerning patients infected with COVID-19 who smoke having poorer outcomes than those who do not.1 Although it is widely known that smoking negatively impacts nearly all disease processes, including cancer, it is likely that the impact of COVID-19 heightened the sense of urgency for smoking cessation. Healthcare providers should be well positioned to seize the moment in advising current smokers that there is no better time than now for smoking cessation. The following is intended to assist healthcare professionals in implementing smoking cessation into everyday care models. A review of the process used in The Center for Lung Cancer Screening and Prevention at Stony Brook Medicine as well as outcome measures will be shared.
The smoking cessation program is built on 4 founding principles:
- Counseling begins with conversation and support.
- Knowledge is power.
- Hope is essential.
- Success increases as counseling frequency increases.
Counseling Begins with Conversation and Support
Twenty-first century healthcare practice is often a delicate balance of distinguished care in a limited time allotment. A number of other variables are added to this balance in the care of the patient either at risk for or diagnosed with cancer. In the cancer arena there are a number of variables regarding attitudes, bias, and stigmas toward patients who smoke that influence patients, professionals, and the community.2 Specifically, behaviors influenced by guilt and shame in the cancer patient should be addressed to maximize success with smoking cessation and provide opportunities to address associated anxiety and depression.3 These barriers to smoking cessation should be addressed in every cancer care clinic to optimize patient outcomes. Tobacco cessation counseling can be effectively given by many healthcare providers in this setting. It is vital that professionals involved in the care of a current smoker, or one who has recently quit, ask about smoking habits and the patient’s willingness to discuss change. Opening questions such as “Is it okay if we talk about your smoking?” and “On a scale of 0 to 10, with zero being ‘no desire to quit’ and 10 being ‘strongest desire to quit,’ where would you rank yourself?” Other quit scale questions include the importance of quitting and readiness to quit. When patients are engaged in such conversations, they feel supported and not judged, and they will often outline the numerous reasons they “should quit” or “want to quit.” Many patients who have received a cancer diagnosis will wonder if smoking cessation will have any impact on outcomes. They may further impose self-punishment for the cancer diagnosis due to smoking. Motivational interviewing has been shown to be a vital skill. It can be employed by healthcare providers to assist patients with quitting and to help them express their feelings toward smoking and quitting.4 Overviews of motivational interviewing, a learned skill set, can be found in a number of publications by Miller and Rollnick.5
Knowledge Is Power
The well-known phrase, “knowledge is power,” proves true in smoking cessation for both the smoker and the tobacco cessation counselor. A general understanding of the addictive properties of smoking and resources available to assist in the quit journey have proved to be helpful in the successful transition of a “current smoker” to a “former smoker.” Of particular importance are the addictive properties of smoking, the brain’s reaction to nicotine, the multisystem effects of smoking addiction, and the details of how various resources assist in smoking cessation.
Knowledge for the tobacco cessation counselor must also include statistics regarding success and the importance of perseverance and multiple attempts, as well as the FDA-approved medications to assist the smoker on the quit journey. Awareness of the addictive properties of smoking is imperative for smokers and their loved ones. It is particularly critical for the patient who has been diagnosed with cancer yet continues to smoke. Guilt and shame scores have been shown to be higher for smokers with serious diagnoses. These emotional responses stay with the patient.6 For the never or former smoker, the idea of continuing to practice a habit that yields major health risks or after one receives a serious diagnosis is baffling. Many smokers also feel this way. Quotes by smokers recently diagnosed with cancer state: “how ridiculous,” “how crazy,” “how foolish” it is to continue to smoke knowing it results in poorer outcomes for many diseases, including cancer, and that it is the leading preventable cause of death and disease worldwide.7 In fact, smoking is predicted to claim 1 billion lives in the 21st century.7 Although smoking claims a staggering number of lives and contributes to nearly every disease process, a big part of the answer to how or why the smoker continues is found in the addictive properties of nicotine. Nicotine is the most powerful of the addictive substances found in cigarettes and is widely accepted as the leading cause of the addictive nature of smoking.8 For those who have studied the multichain addictive properties of nicotine, it is clear that the crusade against smoking includes winning a war against a nicotine addiction. And although nicotine addiction is often thought of as predominantly physical, it is important to recognize that it is woven tightly with the psychological and behavioral addictive powers of smoking.
The physical addictive properties of smoking are predominantly related to receptors called nicotinic acetylcholine receptors that are plaited into the brain at a cellular level.9 Nicotine is a perfect fit for these receptors (thus the name nicotinic cholinergic receptors) because it closely resembles the innately given transmitter, acetylcholine. When nicotine “clicks” into these receptors, there is a resultant firing of nerves and release of chemicals that result in mood enhancement. Dopamine release is believed to be the culprit for smoking addiction as well as other addictive behaviors. The mood enhancement happens either by direct stimulation of the neurotransmitters (chemicals, such as dopamine) or by minimizing withdrawal symptoms. In addition, the chemical release often causes a boost or improvement in mental and physical functions.9 The time for nicotine to reach the brain on inhalation (or a drag) of a cigarette is a quick 10 seconds. Prior to becoming regular smokers, neurotransmitters are naturally released, but after regular smoking, much of the chemical release occurs when the nicotine molecule is transmitted to the brain, and the behavior is associated with smoking to further increase cravings. This has been called “cue-driven smoking urges” or “situational cravings.”10 Thus, the smoker’s brain is said to be rewired. In other words, things that once brought pleasure, such as a cup of coffee, no longer bring the same pleasure unless the activity is accompanied by the nicotine in a cigarette. The smoking-related neurotransmitter activity results in numerous rewarding effects, but eventually more nicotine is required to achieve the same effects (tolerance), which leads to increased smoking. In addition to the physical properties, there are psychological and behavioral addictive properties of smoking. Many smokers express that giving up smoking can be equated to saying goodbye to a best friend. Because the smoker knows the effects of smoking and often associates smoking with various behaviors, situations, and stress release, quitting becomes even more difficult. In addition, the habit has become nearly involuntary for many smokers, with descriptions of smoking without even recalling lighting the cigarette. This multilink chain of addiction becomes very difficult to break.
The good news, however, is that the brain can rewire back to its original state of releasing the feel-good and stress-adapting chemicals without nicotine if given time. Although the time needed varies from person to person, it is possible for all to achieve this. While waiting for the brain to rewire back to its natural state prior to smoking, smokers will experience withdrawal symptoms. These include feeling irritable, angry, or anxious; having difficulty thinking; craving tobacco; and changes in appetite.11 Some patients trying to quit smoking even describe flu-like symptoms. It is imperative that patients be forewarned of withdrawal, be assured it will eventually diminish, and that nicotine replacement and/or medications are available to help manage withdrawal.
The goal for achieving smoking cessation is to minimize withdrawal symptoms and implement alternative stress management and behavior habits. Most experts agree that achieving smoking cessation is most often accomplished with a combination of counseling (either individual, group, or online support), and FDA-approved medications, which include varenicline (Chantix), bupropion (Wellbutrin, Zyban), and nicotine supplements, which include a nicotine patch (continuous nicotine delivery) or nicotine gum, lozenges, inhaler, or nasal spray (intermittent nicotine delivery),12 and relapse prevention. Patients can be given a simple or elaborate description of these. An overall brief description can be as simple as this: “Varenicline (Chantix) assists by occupying the brain’s receptors, while bupropion (Wellbutrin or Zyban) assists via its anticraving effects. Nicotine replacement helps by giving various amounts of nicotine that one would typically get in the cigarette, which can reduce or alleviate withdrawal symptoms.” Patients should be advised that FDA-approved nicotine replacement options can assist with withdrawal symptoms while eliminating the harm of combustible smoking. They should be cautioned about the potential harm of non–FDA-approved nicotine supplements such as e-cigarettes and vaping.
Varenicline became available for smoking cessation in 2006 and has been effective for countless smokers in achieving smoking cessation.13 Patients should be reassured of successful outcomes coupled with education regarding potential side effects to optimize success and ease any wariness about the drug. Patients are often intrigued and interested in varenicline when they are informed that there are 3 options for quitting with the use of the drug. These options include the fixed quit approach, the flexible quit approach, and the gradual quit approach, with dates of quit varying from 1 week, 1 month, and 12 weeks, respectively.14 Patients who are warned of the common but typically manageable side effects, including nausea and stomach upset, headache and moodiness, and vivid dreams, are in a better position for medication success. Other side effects, such as seizure and vascular effects, should be carefully considered before prescribing.
Bupropion is another oral drug option to assist with quitting. It should be considered for the patient who has experienced significant weight gain on past quit attempts or who is concerned about weight gain. Although the drug is not a weight-reducing agent, its anticraving properties often contribute to less food craving as well. Regardless of the tobacco cessation plan, intentional nutrition planning is an important part of the process during any smoking cessation attempt.
Nicotine replacement can be used alone or carefully in conjunction with medications. It is important for prescribers to take a careful history of the patient’s typical smoking pattern. Many smokers will disclose their current smoking frequency on the day of their clinic visit, and unless further questioned they may not disclose their typical smoking frequency. For example, if Mrs A presents for her first dose of chemotherapy and receives tobacco cessation counseling, she may disclose that she smokes 4 cigarettes daily, when in fact she may only recently have reduced the frequency from a much higher rate. An accurate history helps the provider prescribe the appropriate nicotine supplementation. Patients who express concern about persistent nicotine addiction with the use of nicotine supplements can be reassured that the FDA-approved nicotine supplements have been proved to be safe, as opposed to the numerous health hazards of combustible smoking. In addition, patients can be advised that nicotine reduction can be addressed at a later time, but smoking cessation is critical to both their overall health and optimal response to their cancer treatment.
Finally, patients should be made aware of ongoing resources available for support. These include local and state quit lines and support. State support can be found at 1-800-QUIT NOW. Many counties provide ongoing group support and medications at reduced cost. One-to-one texting and telephone support is also often available. Patients benefit from knowing that although there are many who have quit smoking “cold turkey” and without assistance, the success rates of those attempting to quit without assistance is reported to be 5% to 7%. The rate is much higher when resources are utilized.15
Once a smoker has overcome the addiction, relapse prevention is equally important to maintaining quit status, with tips available via the quit lines available in all 50 states. Heightened alert to relapse and intentional relapse prevention measures help minimize the risk.
Hope Is Essential
Of equal importance is maintaining a theme of HOPE throughout the quit journey. The idea of hope being critical stems both from literature revealing the predictive influences of hope coupled with the observed impact of HOPE in the Stony Brook program.16 The feedback from current smokers undergoing tobacco cessation counseling with HOPE as the underlying theme has been positive. Hope as an underlying theme includes deidentified testimonials of other smokers who have succeeded in tobacco cessation as well as statistics of smoking cessation accomplishments and reminders that past failures do not diminish the hope that a smoker has for a new cessation attempt. In fact, patients are often elated when made aware that success is more likely on multiple attempts, which translates into “this quit attempt has a higher rate of being successful than your last one,” based on the literature.17
Hopeful news regarding the healthy benefits of quitting should also be woven into all tobacco cessation counseling sessions. The CDC outlines many positive health benefits of quitting at any age.11 These include, but are not limited to, the decrease in respiratory symptoms and disease, lung and other cancers, heart disease, and stroke.
Success Increases as Counseling Frequency Increases
Although many smokers admit that smoking cessation success is difficult, and healthcare providers are often repeated witness to this, it is important to acknowledge the positive relationship between tobacco cessation success and counseling frequency. It is imperative to recognize the value of recurrent counseling in smoking counseling. Although most healthcare providers are unable to provide recurrent visits, referrals can be made to state quit lines where various accountability avenues exist.18 State quit lines can be reached at 1-800-QUIT-NOW. Patients directed to quit lines when healthcare provider visits are either exhausted or not available will find a number of options for quit assistance, including information, quit apps, text support options, and support groups. And if all else fails, patients can take heart in knowing that “while none is best, less is better.” Making even a small decrease in the frequency of smoking is better for one’s health and positions the smoker for greater success in quitting.
Patients can be encouraged with statements such as these:
Regardless of your age, your history with smoking, your current health status, or any other variable, today is the best day to start or restart your quit journey!
When and if you are committed to that quit journey indefinitely, you will quit.
Repetitive quitters eventually quit for good.
As healthcare providers who are trained in evidence-based medicine, we may find it difficult to implement such practice; however, our program demonstrates such hopeful and positive reinforcement as we note increases in quit success as a result.
The Stony Brook Program
Stony Brook Medicine is a large tertiary care academic facility with 602 inpatient beds and an outpatient base of over 1 million patients annually.19 In addition to adhering to the national mandate that every provider address smoking status and advise smokers to quit at every visit, Stony Brook provides additional tobacco cessation for patients who choose to participate during tobacco cessation clinic visits with a nicotine addiction specialist. The tobacco cessation program is housed in The Center for Lung Cancer Screening and Prevention. Since opening, the center has provided tobacco cessation counseling to hundreds of patients. The philosophies outlined are woven into the counseling sessions, and patients are encouraged to return to the office or follow up with telephone counseling throughout their quit journey and afterward during relapse risk.
A recent study reported at the American Thoracic Society’s Annual Conference by the Stony Brook team reviewed 254 patients enrolled in lung cancer screening between 2013 and 2018 who were currently smoking at the time of first visit, and who underwent 30 minutes of tobacco cessation counseling. The quit rate (defined as 6 months of self-reported smoking abstinence) of 29.5% and cut back rate (CBR; defined as self-reported reduction in smoking frequency by at least 1 cigarette daily) of 9.44% equated to a nearly 40% positive change rate (PCR) in smoking behavior in patients receiving tobacco cessation counseling of this caliber.20 Although this reflects a focused group of high-risk patients, these numbers are convincing in validating the positive influence of a combination of supportive conversation, patient and provider knowledge, along with hopeful and recurrent counsel. Further investigation is needed for specific patient populations for tobacco cessation success, morbidity, and mortality. This tobacco cessation study is the first known to document CBR and PCR in this patient population. Our organization proposes that CBRs and PCRs be strongly considered in future reviews given the well-described relationship between frequency of smoking and disease burden.
Tobacco cessation is a critical, yet often an overlooked or underfocused part of holistic health for any patient group, but especially the patient undergoing treatment for cancer. Brief but effective tobacco cessation counseling at every visit by multiple healthcare professionals with a combined focus on support, knowledge, hope, and recurrence is recommended for increased tobacco cessation success. In addition, nicotine addiction specialists, who can provide dedicated tobacco cessation counseling, can further improve quit rates among patients at risk or undergoing treatment for cancer.
- University of Minnesota. Center for Infectious Disease Research and Policy. Studies: Smoking, age, other factors raise risk of COVID-19 death. www.cidrap.umn.edu/news-perspective/2020/04/studies-smoking-age-oth er-factors-raise-risk-covid-19-death. April 9, 2020. Accessed June 19, 2020.
- Luberto CM, Hyland KA, Streck JM, et al. Stigmatic and sympathetic attitudes toward cancer patients who smoke: a qualitative analysis of an online discussion board forum. Nicotine & Tobacco Research. 2016;2194-2201.
- LoConte NK, Else-Quest NM, Eickhoff J, et al. Assessment of guilt and shame in patients with non-small-cell lung cancer compared with patients with breast and prostate cancer. Clin Lung Cancer. 2008;9:171-178.
- National Alliance on Mental Illness. Motivational Interviewing as a Smoking Cessation Strategy. https://namimn.org/wp-content/uploads/sites/188/ 2018/06/FactSheet_Smoking_MotivationalInterviewing_2018.pdf. 2016.
- Miller W, Rollnick S. Ten things that motivational interviewing is not. Behav Cogn Psychother. 2009;37:129-140.
- Shin DW, Park JH, Kim SO, et al. Guilt, censure, and concealment of active smoking status among cancer patients and family members after diagnosis: a nationwide study. Psychooncology. 2014;23:585-591.
- World Health Organization. WHO Report on the Global Tobacco Epidemic, 2008. The mPOWER package. www.who.int/tobacco/mpower/mpower_report_forward_summary_2008.pdf.
- National Institutes of Health. National Institutes on Drug Abuse. www.drugabuse.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/nicotine-addictive. 2020.
- Benowitz NL. Nicotine addiction. N Engl J Med. 2010;362:2295-2303.
- West R. Tobacco smoking: health impact, prevalence, correlates and interventions. Psychol Health. 2017;32:1018-1036.
- Centers for Disease Control and Prevention. Smoking Cessation: Fast Facts. www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm.
- Mayo Clinic. Healthy Lifestyle: Quit smoking. www.mayoclinic.org/healthy-lifestyle/quit-smoking/in-depth/quit-smoking-products/art-20045599. Accessed June 20, 2020.
- Waknine Y. Medscape. FDA Approvals: Chantix. www.medscape.org/viewarticle/532569. 2006.
- Chantix (varenicline). www.chantix.com/?source=google&HBX_PK= s_+side++effects+of++chantix&skwid=43700037225951008&cmp=db911133-7d82-4ffd-978b-469707df4b75. 2018.
- Zhu S, Melcer T, Sun J, et al. Smoking cessation with and without assistance: a population-based analysis. Am J Prev Med. 2000;18:305-311.
- Mathis GM, Ferrari JR, Groh DR, Jason LA. Hope and substance abuse recovery: the impact of agency and pathways within an abstinent communal-living setting. J Groups Addict Recover. 2009;4:42-50.
- Chaiton M, Diemert L, Cohen JE, et al. Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open. 2016;6:e011045.
- Centers for Disease Control and Prevention. How to Quit Smoking. www.cdc.gov/tobacco/campaign/tips/quit-smoking/index.html?s_cid=OSH_tips_GL0002&utm_source=google&utm_medium=cpc&utm_cam paign=Quit+2020%3BS%3BWL%3BBR%3BIMM%3BDTC%3B CO&utm_content=Quitline_P&utm_term=smoking+quitline&gclid=Cj0K CQjw7qn1BRDqARIsAKMbHDbU3ll_JSib0m0ELcCxxdda8y5TPPMD fK8hZMZpX6WLjqHMZAPnJSYaAm0dEALw_wcB&gclsrc=aw.ds. 2020.
- Stony Brook Medicine. Fast Stats. www.stonybrookmedicine.edu/aboutus/fast-stats. 2020.
- Plank A, Reagan L, Sinha A, et al. Tobacco cessation rates among patients undergoing lung cancer screening coupled with 30 minutes of counseling. Am J Respir Crit Care Med. 2020;201:A4232.