How to Help Patients with Cancer Quit Smoking

Because of the risk for developing secondary malignancies, and given the association between smoking and cancer, all patients who smoke should be counseled about quitting, according to Linda Sarna, PhD, RN, FAAN.

However, Sarna—who is dean, professor, and Lulu Wolf Hassenplug Endowed Chair at UCLA Nursing, acknowledged that oncology healthcare providers often do not feel prepared to discuss smoking cessation with patients. To help improve oncology nurses’ knowledge and ability to raise the topic with patients, she presented a course on the subject at the PER^® 36th Annual CFS^®, held in New York City on Nov. 7.¹

“Reducing tobacco use and exposure to second-hand smoke is critical to reducing unnecessary death and misery,” said Sarna, who is also one of the founders of Tobacco-Free Nurses, an organization designed to enhance nurses’ involvement in all aspects of tobacco control.

Cancer Risk and Smoking Cessation Benefit

Conveying cancer risk to patients is the first step: Almost 2 million cancer deaths per year are related to tobacco, including those of the lung, head and neck, stomach, bladder, kidney, pancreas, cervical, and colon, as well as leukemia.² Among the people who have lung cancer, 80% of cases are caused by smoking.¹

Immediate and long-term health benefits of quitting smoking include improved circulation, increase in lung function, and reduction in risk of cardiovascular disease and stroke.

“After 1 year, the excess risk of coronary heart disease decreases to half of that of the continuing smoker,” Sarna said. “Risk of stroke reduces to half of those who never smoked at 5 years. That's pretty profound.”

After 15 years of being tobacco-free, the risk of cardiovascular disease is similar to that of people who have never smoked at all. In addition, though risk of lung cancer persists for a lifetime among people who have a history of smoking, it will be significantly reduced in those who are able to quit.¹ Those who quit are also likely to reduce their risk of cancer recurrence, treatment complications, and survival.

The 5 As

Because tobacco dependence includes both physiological and behavioral elements, patients must be supported with treatment that addresses each. Pharmacotherapy solutions can treat the physical effects of withdrawal, while behavioral therapy can address the habit that is part of a smoker’s daily life.

A key tool that nurses can use to follow these updated guidelines for advising patients about smoking cessation is a 5-step process called the “5 As”:

• Ask patients about tobacco use at every visit. Electronic health records can be useful in reminding nurses to ask about a patient’s smoking habits.
• Advise patients that quitting is one of the most important things that they can do.
• Assess their willingness to quit. Sarna said most people who smoke do want to quit, but some may not be ready. If they are not, nurses can try and help motivate the patient to want to quit at a later date by providing information about the benefits of quitting.
• Assist patients with a quit plan. Sarna recommended for nurses to set a quit date, ideally within 2 weeks, as an initial goal, and then, to advise them to remove tobacco products from their environment, and discuss anticipated challenges, including nicotine withdrawal. Also, she added, nurses should recommend total abstinence, and encourage the use of an over-the-counter nicotine patch, gum, or lozenge; or give a prescription for varenicline, bupropion SR, nicotine inhaler, or nasal spray, unless contraindicated. Nurses can also recommend the toll-free quit-line, 1-800-QUIT NOW (784-8669), the national access number to State-based quit-line services; or refer to smokefree.gov for government-approved smoking cessation information and aid.
• Arrange for follow-up. Nurses should schedule visits with the patient to review progress.

A brief brochure called “Helping Smokers Quit: A Guide for Clinicians,” summarizing and explaining the 5 As, is available from the Agency for Healthcare Research and Quality; US Department of Health and Human Services Public Health Service. A valuable chart at the end of the document offers suggestions for the clinical use of medications for tobacco dependence treatment. It lists common FDA-approved medications, specifies precautions and contraindications, identifies adverse events, and explains dosage duration and medication availability (whether it is a prescription drug or available over the counter).

E-Cigarettes and Smoking Cessation

Sarna noted that a growing number of smokers are using e-cigarettes, which are not FDA-approved smoking cessation tools, to try to quit smoking, but end up using both cigarettes and e-cigarettes, increasing their nicotine intake.

“If your patients are trying to quit with e-cigarettes, first of all, congratulate them that they are trying to quit. Let them know about the evidence-based, FDA-approved medications. Encourage them, if they are using e-cigarettes, not to have dual use of both smoking and e-cigarettes, and to try to get off those things as quickly as possible,” she said.

The Role of Oncology Nurses

Talking to patients about smoking cessation is part of patient education, which is an important element of the nurse’s role in cancer care. Learning how to comfortably broach the topic, discuss it confidently, and provide patients with resources to quit could give patients a better chance at improved health and survival.

“A growing number of studies support the efficacy of the oncology health team, in terms of helping people quit…. We really need to change practice—prevention and cessation are interventions that are central to what we need to do as oncology nurses.”

References

• Sarna L. The importance of tobacco control in oncology: a nursing perspective. Presented at: PER^® 36th Annual CFS^®; November 7-9, 2018; New York, NY.
• Cancer. World Health Organization website. who.int/en/news-room/fact-sheets/detail/cancer. Published September 12, 2018. Accessed November 27, 2018.