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  MTE08 - Smoking Cessation (ID 52)

  • Event: WCLC 2013
  • Type: Meet the Expert (ticketed session)
  • Track: Prevention & Epidemiology
  • Presentations: 1
  • Moderators:N. n/a
  • Coordinates: 10/28/2013, 07:00 - 08:00, Bayside 101, Level 1

  • 10490

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    MTE08.1 - Smoking Cessation (ID 601)

    07:00 - 08:00  |  Author(s): N.A. Rigotti
    • Abstract
    • Presentation
    • Slides

    Abstract
    Tobacco use is the leading preventable cause of death worldwide, responsible for over 5 million deaths per year. By 2030 there will be more than 8 million tobacco-attributable deaths annually, if present trends continue, and 80% of them will occur in low and middle-income countries. Approximately half of regular smokers will die of a tobacco-related disease, losing an average of ten years of life compared to never smokers. Tobacco use is the major cause of lung cancer, increasing the risk 15-20 fold, and accounts a substantial fraction of the burden of tobacco-attributable mortality. In the U.S., for example, lung cancer is responsible for 29% of tobacco-attributable deaths. Lung cancer risk extends beyond tobacco users to nonsmokers who are exposed to secondhand smoke, who have a 30% higher risk of lung cancer than other nonsmokers. Reducing tobacco smoking is central to the prevention and treatment of lung cancer. The risk of lung cancer declines progressively with time after a smoker quits, reaching an asymptote at 15-20 years after quitting. Most cancer prevention efforts focus on preventing lung cancer by promotion smoking cessation among smokers and preventing smoking initiation by youths. A strong evidence base exists to guide efforts to reduce the harms of tobacco use. Offering tobacco cessation treatment is a core component of the World Health Organization’s Framework Convention on Tobacco Control, the world’s first global health treaty. It complements policy efforts such as increasing tobacco excise taxes, expanding smoke-free areas, conducting public education campaigns, and restricting tobacco promotion. However, there is an important gap. Reducing tobacco use among smokers with diagnosed lung cancer has received far less attention in cancer care than it deserves, despite a small but growing body of evidence to indicate that continuing to smoke after a lung cancer diagnosis increases all-cause mortality, impairs the response to treatment and worsens the toxicity of treatment, whether surgery, radiation, or chemotherapy. Stopping smoking also improves lung cancer patients’ quality of life by reducing symptoms such as dyspnea and fatigue. A majority of patients diagnosed with lung cancer try to quit after the diagnosis, and effective treatments are available. However, clinicians caring for smokers with lung cancer often neglect to address this issue and to connect smokers to treatment to help them sustain tobacco abstinence. The randomized controlled clinical trial evidence supporting the efficacy of treatments for tobacco use is strong. Systematic reviews agree that effective smoking cessation treatments exist and help many smokers to quit. Proven treatment methods fall into two major categories: psychosocial counseling (also called behavioral support) and pharmacotherapy. Each of these modalities is effective, but combining behavioral support and pharmacotherapy enhances success because the treatments are complementary. Pharmacotherapy primarily relieves nicotine withdrawal symptoms, while counseling aims to improve a smoker’s motivation and confidence to quit and teaches practical coping skills for quitting. Counseling can be delivered in person or by telephone (either voice or text messaging). The evidence base for the efficacy of delivery via the web or smart phone applications is being developed. Smoking cessation pharmacotherapy approximately doubles the success rate of a quit attempt. Three categories of first-line treatment are approved in the U.S. and many other countries: nicotine replacement therapy (NRT), bupropion (an atypical antidepressant), and varenicline (a selective nicotine receptor partial agonist). NRT, the most widely used product, is available in multiple forms including skin patch, gum, lozenge or sublingual tablet, oral inhaler, mouth spray and nasal spray. Combining NRT products (patch plus a shorter acting form) is the most effective way to administer NRT and is recommended by U.S. and U.K. clinical guidelines. Varenicline, the newest product to market, is effective but enthusiasm has been tempered by post-marketing concerns about psychiatric side effects and a possible increased risk of cardiovascular events. Current evidence does not suggest a large adverse effect but studies are ongoing. Cytisine, a partial nicotinic receptor agonist that is less selective for the α4β2 nicotinic receptor than varenicline, is inexpensive and sold in some Eastern European countries. It showed efficacy for smoking cessation in a recent double-blind randomized controlled trial although quit rates were low. If replicated, its low cost could make pharmacotherapy affordable in settings where cost limits medication availability. Nortriptyline, a tricyclic antidepressant, has evidence of efficacy in systematic reviews but is supported by a smaller body of evidence. No other antidepressant and no anti-anxiety medication has demonstrated efficacy for smoking cessation. To date there are few trials of smoking cessation interventions specifically targeted to patients with cancer. However, there is substantial evidence about what works in ambulatory and inpatient medical practice, and this is likely to be generalizable to lung cancer patients. Physicians who routinely deliver brief advice to quit to all smokers increase smokers’ odds of quitting. Providing a brief counselling intervention during an office visit is more effective than advice alone at promoting smoking cessation. Clinicians in ambulatory practice can promote smoking cessation by encouraging a smoker to make a quit attempt and connecting the smoker to evidence-based medication and behavioural treatments available in the health care system or community. Caring for hospitalized smokers provides another opportunity to encourage smoking cessation. Hospital-initiated smoking cessation counselling interventions increase cessation rates after discharge. A system-wide approach to promoting and supporting smoking cessation should be part of standard care in cancer centers and other sites that deliver health care to cancer patients. This would include the systematic identification and documentation of smoking status throughout cancer treatment, routine and repeated offers of tobacco cessation treatment during cancer treatment, and coordination of care among various types of specialists who deliver the cancer care. In our institution, we conducted a pilot trial in newly diagnosed patients with early stage lung cancer to identify smoking status and routinely offer treatment. We compared 12 weeks of varenicline plus counselling with usual care. At end of treatment, quit rates were higher with treatment (34% vs. 14%), and a full-scale randomized trial is underway.

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