Care for Smoking Cessation Must Be Proactive and Based on a Combination of Pharmacology and Psychology.

Abstract

Price and colleagues’ call for more effective smoking cessation in cancer patients is most welcome but deserves comment [1]. First, the finding that “>75% [of oncology care clinicians] assess tobacco use during an intake visit and >60% typically advise patients to quit, a substantially lower percentage recommend or arrange smoking cessation treatment” [1] is neglect of a major health concern, rather than an issue about improvements in quality of care. Indeed, tools for improvement are overlooked. In 2012, the Joint Commission suggested improving the quality of the Tobacco Cessation Performance Measure Set (TOB) by asking hospitals to document a fourth item: “tobacco-use status approximately 30 days after discharge” (TOB-4). In 2015, only 671 hospitals reported on the TOB (vs. an average of 3,254 reporting data on other topics), and none on the TOB-4, as in 2014. Data collection was then suspended [2]. Second, the “5As” motto and, specifically, “Advising users to quit” is almost designed to fail [3]. Tobacco is among the most addictive products; all smokers will have made serial attempts to quit, almost always failures with suffering and despair. “Assessing willingness to quit” is putting the cart before the horse. Very few smokers expect to be able to quit, and the cancer diagnosis visit is hardly a propitious moment for planning cessation. Patients need reassurance first! I explain that nicotine patches will help them to reduce smoking without effort and that I do not require them to quit. Misconceptions are common, and patients need indepth explanations with reflexive listening because they (a) wrongly are more scared of nicotine than of carbon monoxide or tar and (b) are not aware of the devastating effects of compensatory uptake when trying to reduce tobacco use without substitutes. It is less dangerous to smoke with patches, which allow smoking less, without suffering. The “belt and braces” strategy doubles odds of quitting, combining patches with oral “rescue” formulations of nicotine (i.e., sprays and lozenges) to suppress occasional cravings [4]. Given that craving is simply a form of pain, nicotine dose levels must be increased until the pain has been suppressed. Although dose-response is a basic pharmacological principle for effectiveness, most prescriptions are under-dosed as a result of misconceptions about safety [5]. In my experience, many patients need two 21 mg patches, some even three. Suppressing cravings and making smoking distasteful can take a few months. Then patients understand that they can plan a date for quitting, being warned that the failure would be the lack of planning rather than the lack of success of the attempt. For those reluctant to quit after simple explanations, motivational interviewing is very effective; it needs skills and time, but the results are worth it [6]. Sadly, motivational interviewing is not widely available [7]. Proactive care is mandatory for smoking cessation. Smoking cessation must be a priority for health care professionals and not just for patients with cancer. However, inertia is deeply ingrained. For example, women who smoke will at best be prescribed progestin-only pills or intrauterine devices when seeking contraception, but very few will get help for their addiction—even though half of smokers will die from smoking. Similarly, people attending cancer screening programs too rarely benefit from multidisciplinary lifestyle interventions by trained professionals to treat major obvious risk factors (smoking, alcohol use, obesity, physical inactivity, etc.) [8].