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Carolyn Dresler
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OA09 - Lung Cancer: A Preventable Disease? (ID 134)
- Event: WCLC 2019
- Type: Oral Session
- Track: Prevention and Tobacco Control
- Presentations: 9
- Now Available
- Moderators:Bienvenido Barreiro, Carolyn Dresler
- Coordinates: 9/09/2019, 11:00 - 12:30, Melbourne (1991)
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OA09.01 - Opt-Out Smoking Cessation Program in Lung Cancer Screening Provides Excellent Quit Rates (Now Available) (ID 2141)
11:00 - 12:30 | Presenting Author(s): Renelle Myers | Author(s): Sukhinder Kaur Atkar-Khattra, Stephenie Pillainayagam, Simroop Ladhar, Kelley Cho, Maria Janicker, Jennifer Callaghan, John Yee, Stephen Lam
- Abstract
- Presentation
Background
The most effective way to integrate smoking cessation into lung cancer screening has not been established. The opt -out approach has been shown to produce quit rates in those ‘not interested in quitting’ to equal quit rate in those individuals ‘ready to quit.’ The BC Lung Screen Trial recruits ever smokers 55 to 80 years of age who meet either the PLCOm2012 6 years lung cancer risk ≥1.5% or USPSTF smoking criteria. The purpose of this study is to prospectively evaluate the smoking cessation rate of current smokers using an opt-out approach.
Method
Screened participants who were interviewed for screening eligibility were given brief, 10 minute, smoking cessation counselling in-person by a research assistants(RA) trained in smoking cessation. They discussed the health benefits of smoking cessation and outlined resources available including free nicotine replacement therapy. All participants were given an information pamphlet and automatically referred to QuitNow; the provincial telephone based smoking cessation line. They were then contacted by the study staff at 3 and 6 months to determine smoking status.
Result
Between January 2018 and Jan 2019, 396 current smokers participated in a face to face interview prior to screening and 355 (90%) accepted referral to QuitNow. All of these participants were contacted by QuitNow/study staff. 309 (87%) accepted some form of cessation service including telephone counselling, text messaging, on-line coaching, pharmacotherapy or a combination of services. Of those accepting a service, the 3 and 6-month self-reported quit rate was 27% with 75% of participants who quit used telephone or online coaching.
Conclusion
Most current smokers participating in a lung cancer screening program are interested in smoking cessation. Of those who accept some form of smoking cessation counselling service, an excellent (27%) quit rate was observed using an opt-out approach.
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OA09.02 - Smoking Cessation Counseling in a Surgical Clinic Is Effective (Now Available) (ID 2772)
11:00 - 12:30 | Presenting Author(s): Matthew Allen Steliga | Author(s): Claudia P Barone, Patricia L Franklin, Jason L Muesse, Nicholas D Tingquist
- Abstract
- Presentation
Background
Many patients in a thoracic surgery oncology clinic are unable to quit despite referral for tobacco related illnesses and the knowledge that smoking is harmful. Continued smoking leads to poorer outcomes in cancer patients. We implemented individualized counseling for all patients in our ambulatory clinic as a standard part of their cancer care using an opt-out framework. All patients were surveyed for use, and cessation support consisted of individual counseling and pharmacotherapy tailored to the individual.
Method
All patients in the thoracic surgery oncology clinic were surveyed for tobacco use at the intake for each visit. Any patient who was a current tobacco user met with a certified tobacco treatment specialist (CTTS) in the surgery clinic in the exam room before and/or after meeting with the surgeon. This was introduced as a standard part of the patient’s treatment plan; patients could opt-out if they chose. Less than 5% of patients who were offered the counseling declined. The cessation counseling was reinforced by the surgeon, and patients were informed about how cessation could improve outcomes. On return visits, the patients met with the CTTS for follow up counseling and feedback. Data was prospectively entered in an IRB approved database for tracking smoking cessation outcomes at our institution. Retrospectively data was harvested for the prior 17 consecutive months.
Result
Over a consecutive 17 months, a total of 275 patients who were currently smoking were seen in the thoracic surgery oncology clinic by two thoracic surgeons and met with a CTTS for individualized counseling which included a cessation plan and pharmacotherapy tailored to the individual. Follow up information was available on 87% of patients 240/275. Of the 240 patients who were smoking and met with a CTTS for an individualized plan, 2.9% increased their smoking (7/240), 23.3% had no change (56/240), 29.2 decreased (70/240), and 44.6% quit (107/240) on follow up visits. Cessation was validated by a handheld exhaled breath carbon monoxide (CO) detector whenever possible, and often decreased smoking rates were validated with lower CO readings as well.
Conclusion
Patients in a thoracic surgery oncology are receptive to counseling by a CTTS when provided at the point of care. Despite heavy smoking histories, many of the patients in a thoracic surgery oncology clinic can quit smoking with evidence based support including counseling, pharmacotherapy, and follow up. As cessation improves treatment outcomes in many facets of lung cancer care, cessation support should be integrated in a standard workflow for all patients.
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OA09.03 - Patterns of Birth Cohort-Specific Smoking Histories by Family Income in the USA, 1982-2017 (Now Available) (ID 2734)
11:00 - 12:30 | Presenting Author(s): Jihyoun Jeon | Author(s): Pianpian Cao, Danny Luan, Jamie Tam, David T Levy, Nancy L Fleischer, Theodore R Holford, Rafael Meza
- Abstract
- Presentation
Background
Although cigarette smoking has been declining significantly in the US over last several decades, disparities in tobacco use remain across different groups by race/ethnicity, education, socioeconomic status (SES), or regions. Specifically, people in lower family income have higher smoking prevalence, longer smoking durations and lower cessation rates than other income groups. However, little is known about how smoking patterns, including rates of initiation, cessation, and intensity, differ by birth cohort across various income levels.
Method
Using the National Health Interview Survey (NHIS) family income data, we calculated individual income-to-poverty ratios from 1982-2017. Missing family income data from 1982-1996 was imputed using a sequential regression multivariate imputation method, the NHIS approach to impute missing continuous income from 1997-2017. Age-period-cohort models with constrained natural splines were used to estimate the annual probabilities of smoking initiation, cessation, and intensity by sex and birth-cohort for five income-to-poverty ratio groups (<1, 1-2,2-3,3-4 and 4+ times the poverty threshold). Age- and sex-specific smoking prevalence was also estimated for different income groups and birth cohorts.
Result
Smoking prevalence and initiation rates are decreasing by birth-cohort in all income-to-poverty ratio groups, while cessation rates are increasing. However, the relative smoking prevalence between low- and high-income groups is markedly increasing by birth-cohort (Figure 1). Smoking initiation probabilities are highest among those living below the poverty threshold, and inversely associated with income level. Conversely, people living below the poverty threshold have the lowest probabilities of quitting, with increasing smoking cessation probabilities in higher income groups. Age-specific smoking cessation probabilities vary considerably by income, especially in recent birth-cohorts for both men and women.
Figure 1. Age-specific current smoker prevalence for females (upper panels) and males (lower panels) for five income-to-poverty ratio groups (<1, 1-2,2-3,3-4 and 4+ times the poverty threshold) and selected birth cohorts.
Conclusion
Smoking prevalence has been decreasing in all income groups, however, disparities in smoking pattern between high and low-income populations are increasing with more recent birth-cohorts. Future studies evaluating disparities in smoking should account for differences by birth-cohort. The establishment of effective smoking intervention strategies specifically for low-income groups will be important to reduce tobacco-related health disparities.
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OA09.04 - Discussant - OA09.01, OA09.02, OA09.03 (Now Available) (ID 3762)
11:00 - 12:30 | Presenting Author(s): Magdalena Cedzynska
- Abstract
- Presentation
Abstract not provided
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OA09.05 - Lung Cancer as a Second Primary Malignancy Among Women with Breast Cancer: The Role of Hormone Replacement and Smoking (Now Available) (ID 1430)
11:00 - 12:30 | Presenting Author(s): J. Nicholas Bodor | Author(s): Susan G Fisher, Joseph Treat, Margie L Clapper
- Abstract
- Presentation
Background
Women are more susceptible to tobacco-related lung tumorigenesis, and makeup a disproportionate number of lung cancer cases among never-smokers. This gender bias has prompted an investigation of the role of hormonal factors in lung tumorigenesis. Most breast cancers are hormone-mediated. Likewise, emerging evidence suggests that estrogen metabolites may contribute to lung tumorigenesis. Patients with a dual diagnosis of a primary lung and a primary breast cancer are of interest, as their development may be hormonally-driven. This research studies this by examining a cohort of women with breast cancer to assess hormone use, its interaction with cigarette smoking, and the risk of developing lung cancer as a second primary malignancy.
Method
A secondary analysis of the Women’s Health Initiative (WHI) clinical trial and observational study cohorts was performed and was restricted to patients with a diagnosis of breast cancer. Women 50 to 79 years of age were enrolled from October 1, 1993 to December 31, 1998, and follow-up ended on September 30, 2010. A total of 9,593 incident breast cancers were diagnosed and of these women, 120 had a subsequent primary lung cancer. Multivariable logistic regression was performed to test associations between hormone use, smoking history, reproductive factors, and the risk for lung cancer as a second primary malignancy. All predictor variables were assessed at enrollment/baseline.
Result
While current hormone use at baseline was not independently associated with risk for developing lung cancer as a second primary, current smoking at baseline was an independent predictor of risk (OR: 3.2, p=0.001). Among women with breast cancer who were both current smokers and current users of hormone replacement, the risk of lung cancer was significantly increased (OR: 7.7, p=0.024) compared to women who were not current smokers and not current users of replacement hormones.
Conclusion
Hormone replacement may increase the risk for lung cancer as a second primary malignancy in smoking breast cancer patients. Although hormone therapy is no longer preferable, this finding suggests an interplay between estrogen exposure and smoking, which may contribute to the greater susceptibility of women for smoking-related lung cancer. These data are consistent with results from preclinical studies by this group that indicate that smoking induces cytochrome P450 1B1, leading to higher levels of the putative carcinogenic estrogen metabolite 4-hydroxyestrogen in lung tissue. Smoking increased the risk of a second lung malignancy in this study, independent of hormone use, and tobacco cessation should be encouraged for all patients with breast cancer.
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OA09.06 - Residential Radon, Smoking and Lung Cancer Risk. A Case-Control Study in a Radon Prone Area (Now Available) (ID 1260)
11:00 - 12:30 | Presenting Author(s): Alberto Ruano-Ravina | Author(s): María Lorenzo-González, Mariano Provencio, María Torres-Durán, Isaura Parente-Lamelas, Iria Vidal-García, Juan Barros-Dios
- Abstract
- Presentation
Background
Residential radon is the second risk factor of lung cancer following tobacco consumption and the main one in never smokers, according to the WHO and USEPA statements. The joint effect of tobacco and radon exposure has been little studied and residential radon is a neglected risk factor of this disease. We aim to show lung cancer risk for different combinations of tobacco consumption and residential radon exposure on the risk of lung cancer.
Method
Pooling case-control study in a radon-prone area where we have combined individual information from 5 different multicentric case-control studies. 11 Spanish hospitals from 4 different regions have taken part. All case-control studies had a similar methodology, including incident, primary, and histologically confirmed lung cancer cases and controls attending hospital for trivial surgery not related with tobacco consumption. Cases and controls were older than 30 and controls were matched with cases using a frequency-based sampling using age and gender distribution of cases. Detailed information was obtained regarding tobacco consumption, and a radon device was placed in the participants’ dwelling for at least three months. We calculated lung cancer risk for each category of tobacco consumption and radon exposure taking as a reference those participants never smokers and with an indoor radon concentration below 50 Bq/m3. All Odds Ratios are accompanied by their 95% confidence intervals.
Result
We included 1691 cases and 1698 controls with a similar distribution on age and gender. Heavy smokers exposed to low radon concentrations (< 50Bq/m3) posed a risk of lung cancer of 12.6, compared to 31.3 for heavy smokers exposed to indoor radon higher than 200 Bq/m3. The different odds ratios and confidence intervals for each category of exposure appear in the Table.
Conclusion
There is an interaction between indoor radon and tobacco. Risk of lung cancer increases significantly when both risk factors are present.
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OA09.07 - Implementing an Opt-Out Approach to Smoking Cessation Referrals for Cancer Patients in Ontario, Canada (Now Available) (ID 2728)
11:00 - 12:30 | Presenting Author(s): William K. Evans | Author(s): Erin Cameron, Mohammad Haque, Naomi Schwartz, Sahara Khan, Sargam Rana, Rebecca Truscott
- Abstract
- Presentation
Background
Smoking is responsible for approximately 30% of all cancer deaths in Canada and more than 85% of lung cancer cases. Continued smoking results in decreased cancer treatment efficacy and safety, increased toxicities, greater risk of cancer recurrence and second primaries, poorer quality of life and decreased survival. Quitting smoking can reduce these adverse effects. In 2013, Cancer Care Ontario (CCO) implemented a smoking cessation program across 14 Regional Cancer Centres (RCCs) in the province of Ontario, Canada, employing a 3As (Ask, Advise, Act) brief intervention model.
Method
In the first few years of the program, smokers could “opt-in” to smoking cessation services by stating a readiness to quit. However, the provincial rate of smokers accepting support was low. In 2018, CCO adopted an “opt-out” approach, based on emerging evidence and feedback from an expert Advisory Committee. With this approach, healthcare providers (HCPs) automatically refer all smokers to a cessation service, without assessing the patient’s readiness to quit. Patients can refuse the referral if they choose. This program change was communicated to the RCCs through a revised program framework, site-specific action plans, and discussion during monthly knowledge exchange meetings with Regional Champions. Communications resources (posters and pocket cards) were created to support HCPs, with suggested scripts.
Result
The Accepted a Referral (proportion of smokers accepting referral to cessation services) performance metric was used to monitor program implementation. With an opt-in approach, the annual provincial rate of Accepted a Referral improved only slightly over three years (18.1% in 2015/16 to 22.5% in 2017/18). Just prior to launching the opt-out approach in Q3 of 2017/18, the provincial rate of Accepted a Referral was 23.3% (range 9.2% to 37.9% amongst 14 RCCs). One year later, the provincial rate had increased substantially to 31.9% (range 12.9% to 88.7%). Several RCCs showed dramatic increases, while others demonstrated little or no improvement.
Conclusion
In an effort to help more patients quit smoking and to achieve the best treatment outcomes possible, CCO adopted an opt-out approach to cessation referrals. Overall, there has been a substantial increase in the provincial rate of smokers accepting support, but implementation has varied amongst RCCs. Feedback indicates that while some HCPs found the approach relatively easy to implement, others have been resistant to change, expressing concern about the ethics of referring patients without assessing willingness to quit. Further research into the reasons behind the variable uptake of the opt-out approach will inform future implementation efforts.
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OA09.08 - Discussant - OA09.05, OA09.06, OA09.07 (Now Available) (ID 3763)
11:00 - 12:30 | Presenting Author(s): Haval Balata
- Abstract
- Presentation
Abstract not provided
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OA09.09 - IASLC Lectureship Award for Smoking Cessation (ID 3903)
11:00 - 12:30 | Presenting Author(s): Emily Stone
- Abstract
Abstract not provided
Author of
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MS15 - How to Get Patients to Quit Smoking; Practical Implementation of Evidence-Based Cessation Practices (ID 78)
- Event: WCLC 2019
- Type: Mini Symposium
- Track: Prevention and Tobacco Control
- Presentations: 2
- Now Available
- Moderators:Nico Van Zandwijk, Claudio Martin
- Coordinates: 9/10/2019, 11:30 - 13:00, Dublin (1997)
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MS15.02 - Pharmacotherapy Supports Cessation (Now Available) (ID 3526)
11:30 - 13:00 | Presenting Author(s): Carolyn Dresler
- Abstract
- Presentation
Abstract
Tobacco Cessation and its pharmcotherapy
It should be acknowledged that smoking cessation is one of the hardest things the patient has ever tried to do. There are two key aspects to tobacco cessation: appropriate pharmacotherapy and behavioral modification. This abstract will address only the pharmacotherapy, but the practitioner must also try to provide or refer to behavioral modication interventions to amplify the effect of the pharmacotherapy.
TYPES OF MEDICATIONS: The most common type of medication for quitting smoking is called ‘nicotine replacement therapy’ or ‘NRT”. NRT that has had regulatory approval comes as a gum, a lozenge, or a transdermal patch, or in a device that you ‘smoke’ like a cigarette’ or a nasal spray. In the United States, the nicotine gum, nicotine lozenge and nicotine patch can be purchased without a doctor’s prescription. The device that is ‘smoked’ (I call an inhaler or inhalator - as it is mostly absorbed by buccal mucosa) and the nasal spray must have a doctor’s prescription.
Varenciline is a pill that is taken once in the morning and once in the evening. This medication requires a doctor’s prescription. This drug does not yet (as of 2019) come in a generic form.
To use varenicline – take 0.5 mg by mouth once in the morning for 3 days. On the fourth day – take 0.5 mg by mouth once in the morning and once in the evening. On the 7th day the person should QUIT SMOKING and use 1 mg by mouth once in the morning and once in the evening. Use varenicline for at least 3 months. A discussion between doctor and patient should occur if a longer term treatment period is needed to maintain cessation.
Bupropion is also taken as a pill once in the morning and once in the evening. This medication should not be taken if there is any risk of a seizure, alcoholism, or anorexia. This drug does come as a generic and requires a doctor’s prescription.
To use bupropion: Take 150 mg by mouth once a AM for 3 days. On the fourth day, take 150 mg by mouth once q AM and a PM. On the 7th day – quit smoking. Use bupropion for at least 3 months. A discussion between doctor and patient should occur if a longer term treatment period is needed to maintain cessation.
NICOTINE REPLACEMENT THERAPY:
Nicotine gum: the labeling on the box states that if more than 25 cigarettes per day are smoked, use the 4 mg dose and if less than 25 cigarettes are smoked per day, use the 2 mg dose. However, one can try either and see which dose works better in relieving or preventing cravings for a cigarette. It is very important to take the nicotine gum frequently! Most people do not take enough of the gum during the day to be effective. Instruct the quitter to use at least 9 pieces in the first days of quitting.
One should SLOWLY taper down. Plan on having the quitter using the gum for at least 3 months! The worst day is the first day, and then the first week. After about 7-10 days, all of the nicotine and its breakdown products are cleared from the system and the body is starting to become normal again. It is probable that the quitter is still having cravings – and the nicotine gum will help prevent them and make the cravings more manageable.
NICOTINE LOZENGE: The nicotine lozenge has a little bit different dosing instruction: if the first cigarette of the day is within 30 minutes after waking up in the morning – use the 4 mg nicotine lozenge. If the first cigarette of the day is had after 30 minutes after getting up – use the 2 mg nicotine lozenge. Again – one can try one and see how it works in relieving cravings without any side effects. If it doesn’t seem to relieve cravings – try the other, higher dose. Follow the same instructions above for the gum. AGAIN – it is important to be sure and use enough lozenges per day – the most common problem is people NOT using enough lozenges per day.
NICOTINE PATCH: The nicotine patch comes in a variety of doses and dosing instructions. Most commonly, people use the 15 mg dose (Nicotrol or generic patch) or the 21 mg patch (Nicoderm, Habitrol or generic). These patches should be put on an area of clean and dry skin. It can be put anywhere on the body, but it is best to put it somewhere on the upper body. Try to put it on a place that is not hairy – so it doesn’t hurt when taken it off! Don’t put it on the hips where one might sit on it, don’t put it under the breast – these places are just common sense places NOT to put the patch. The best place is somewhere on the chest, upper back or arms. It is important to put the new patch on each morning in a DIFFERENT place than the patch before. Some skin redness is common, and it should resolve in the next day or so – but it is important to NOT keep using the same place to put the patch.
After about 8 weeks on the highest dose patch, the quitter should start to ‘step-down’ the dose and use the 14 mg or the 7 mg patch. These decreasing doses are intended to help wean the quitter off of nicotine. Of course, the smaller amount of nicotine will also help with the decreasing cravings and withdrawal symptoms as they get further from the quit date.
Even if there is a slip - the quitter has had even one puff – it doesn't mean failure. If there is a slip, work with the quitter, resolve to ‘get back on the wagon’ and not to have another cigarette. They should learn from the experience about what made that ‘slip’ occur and try and stay away from that temptation again.
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MS15.04 - Approaching Cessation in the Patient Using Electronic Cigarettes (Now Available) (ID 3528)
11:30 - 13:00 | Presenting Author(s): Carolyn Dresler
- Abstract
- Presentation
Abstract not provided
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