Benjamin A. Toll

Assessing tobacco use by cancer patients and facilitating cessation: an American Association for Cancer Research policy statement.

When diagnosed with cancer, patients can immediately make a meaningful positive impact on their health by stopping their tobacco use. Scientific evidence clearly shows that tobacco use in patients with cancer leads to poorer outcomes. The specific biological processes driving tobacco consumptions interference in cancer therapy are the subject of continuing research, but the evidence is clear that tobacco use in patients with cancer leads to decreased treatment efficacy and safety, decreased survival, decreased quality of life, increased treatment-related toxicity, and increased risk of cancer recurrence and second primary tumors. Data suggest that tobacco cessation can improve outcomes and survival in patients with cancer, yet full execution of evidence-based cessation interventions is infrequent in oncology settings. Therefore, both improved provision of cessation assistance to all patients with cancer who use tobacco or have recently quit and further study of the deleterious effects of tobacco use and benefits of tobacco cessation on cancer progression and treatment are needed and recommended by the American Association for Cancer Research. Progress on both fronts begins with universal assessment and documentation of tobacco use as a standard of quality cancer care regardless of treatment setting and will be further facilitated through the development of reliable, valid, and standard measures of tobacco use, incorporation of evidence-based procedures into quality and accreditation procedures, and the development of appropriate training, clinical infrastructure, and incentives for delivery of tobacco cessation interventions. Clin Cancer Res; 19(8); 1941–8. ©2013 AACR.

Electronic Nicotine Delivery Systems: A Policy Statement From the American Association for Cancer Research and the American Society of Clinical Oncology

Combustible tobacco use remains the number-one preventable cause of disease, disability, and death in the United States. Electronic nicotine delivery systems (ENDS), which include electronic cigarettes, are devices capable of delivering nicotine in an aerosolized form. ENDS use by both adults and youth has increased rapidly, and some have advocated these products could serve as harm-reduction devices and smoking cessation aids. ENDS may be beneficial if they reduce smoking rates or prevent or reduce the known adverse health effects of smoking. However, ENDS may also be harmful, particularly to youth, if they increase the likelihood that nonsmokers or former smokers will use combustible tobacco products or if they discourage smokers from quitting. The American Association for Cancer Research (AACR) and the American Society of Clinical Oncology (ASCO) recognize the potential ENDS have to alter patterns of tobacco use and affect the health of the public; however, definitive data are lacking. The AACR and ASCO recommend additional research on these devices, including assessing the health impacts of ENDS, understanding patterns of ENDS use, and determining what role ENDS have in cessation. Key policy recommendations include supporting federal, state, and local regulation of ENDS; requiring manufacturers to register with the US Food and Drug Administration and report all product ingredients, requiring childproof caps on ENDS liquids, and including warning labels on products and their advertisements; prohibiting youth-oriented marketing and sales; prohibiting child-friendly ENDS flavors; and prohibiting ENDS use in places where cigarette smoking is prohibited. This policy statement was developed by a joint writing group composed of members from the Tobacco and Cancer Subcommittee of the American Association for Cancer Research (AACR) Science Policy and Government Affairs (SPGA) Committee and American Society of Clinical Oncology (ASCO) Tobacco Cessation and Control Subcommittee of the Cancer Prevention Committee (CaPC). The statement was reviewed by both parent committees (ie, the AACR SPGA Committee and the ASCO CaPC) and was approved by the AACR Boards of Directors on August 6, 2014, and the ASCO Executive Committee on September 18, 2014. This policy statement was published jointly by invitation and consent in both Clinical Cancer Research and Journal of Clinical Oncology. Copyright 2015 American Association for Cancer Research and American Society of Clinical Oncology. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or storage in any information storage and retrieval system, without written permission by the American Association for Cancer Research and the American Society of Clinical Oncology.

Addressing Tobacco Use in Patients With Cancer: A Survey of American Society of Clinical Oncology Members

PURPOSEnAssessing tobacco use and providing cessation support is recommended by the American Society for Clinical Oncology (ASCO). The purpose of this study was to evaluate practice patterns and perceptions of tobacco use and barriers to providing cessation support for patients with cancer.nnnMETHODSnIn 2012, an online survey was sent to 18,502 full ASCO members asking about their practice patterns regarding tobacco assessment, cessation support, perceptions of tobacco use, and barriers to providing cessation support for patients with cancer. Responses from 1,197 ASCO members are reported.nnnRESULTSnAt initial visit, most respondents routinely ask patients about tobacco use (90%), ask patients to quit (80%), and advise patients to stop using tobacco (84%). However, only 44% routinely discuss medication options with patients, and only 39% provide cessation support. Tobacco assessments decrease at follow-up assessments. Most respondents (87%) agree or strongly agree that smoking affects cancer outcomes, and 86% believe cessation should be a standard part of clinical cancer care. However, only 29% report adequate training in tobacco cessation interventions. Inability to get patients to quit (72%) and patient resistance to treatment (74%) are dominant barriers to cessation intervention, but only 8% describe cessation as a waste of time.nnnCONCLUSIONnAmong ASCO members who responded to an online survey about their practice patterns regarding tobacco, most believe that tobacco cessation is important and frequently assess tobacco at initial visit, but few provide cessation support. Interventions are needed to increase access to tobacco cessation support for patients with cancer.

Tobacco Assessment in Actively Accruing National Cancer Institute Cooperative Group Program Clinical Trials

PURPOSEnSubstantial evidence suggests that tobacco use has adverse effects on cancer treatment outcomes; however, routine assessment of tobacco use has not been fully incorporated into standard clinical oncology practice. The purpose of this study was to evaluate tobacco use assessment in patients enrolled onto actively accruing cancer clinical trials.nnnMETHODSnProtocols and forms for 155 actively accruing trials in the National Cancer Institutes (NCIs) Clinical Trials Cooperative Group Program were evaluated for tobacco use assessment at enrollment and follow-up by using a structured coding instrument.nnnRESULTSnOf the 155 clinical trials reviewed, 45 (29%) assessed any form of tobacco use at enrollment, but only 34 (21.9%) assessed current cigarette use. Only seven trials (4.5%) assessed any form of tobacco use during follow-up. Secondhand smoke exposure was captured in 2.6% of trials at enrollment and 0.6% during follow-up. None of the trials assessed nicotine dependence or interest in quitting at any point during enrollment or treatment. Tobacco status assessment was higher in lung/head and neck trials as well as phase III trials, but there was no difference according to year of starting accrual or cooperative group.nnnCONCLUSIONnMost actively accruing cooperative group clinical trials do not assess tobacco use, and there is no observable trend in improvement over the past 8 years. Failure to incorporate standardized tobacco assessments into NCI-funded Cooperative Group Clinical Trials will limit the ability to provide evidence-based cessation support and will limit the ability to accurately understand the precise effect of tobacco use on cancer treatment outcomes.

Research Priorities, Measures, and Recommendations for Assessment of Tobacco Use in Clinical Cancer Research

There is strong evidence that cigarette smoking causes adverse outcomes in people with cancer. However, more research is needed regarding those effects and the effects of alternative tobacco products and of secondhand smoke, the effects of cessation (before diagnosis, during treatment, or during survivorship), the biologic mechanisms, and optimal strategies for tobacco dependence treatment in oncology. Fundamentally, tobacco is an important source of variation in clinical treatment trials. Nevertheless, tobacco use assessment has not been uniform in clinical trials. Progress has been impeded by a lack of consensus regarding tobacco use assessment suitable for cancer patients. The NCI-AACR Cancer Patient Tobacco Use Assessment Task Force identified priority research areas and developed recommendations for assessment items and timing of assessment in cancer research. A cognitive interview study was conducted with 30 cancer patients at the NIH Clinical Center to evaluate and improve the measurement items. The resulting Cancer Patient Tobacco Use Questionnaire (C-TUQ) includes “Core” items for minimal assessment of tobacco use at initial and follow-up time points, and an “Extension” set. Domains include the following: cigarette and other tobacco use status, intensity, and past use; use relative to cancer diagnosis and treatment; cessation approaches and history; and secondhand smoke exposure. The Task Force recommends that assessment occur at study entry and, at a minimum, at the end of protocol therapy in clinical trials. Broad adoption of the recommended measures and timing protocol, and pursuit of the recommended research priorities, will help us to achieve a clearer understanding of the significance of tobacco use and cessation for cancer patients. Clin Cancer Res; 22(8); 1907–13. ©2016 AACR.

Feasibility of Implementing a Hospital-Based "Opt-Out" Tobacco-cessation Service.

ObjectivenTo assess the feasibility and outcomes of implementing a hospital-based opt-out tobacco-cessation service.nnnMethodsnIn 2014, the Medical University of South Carolina adopted a policy that all hospitalized patients who self-report using tobacco be referred to tobacco-cessation service. This is a descriptive study of a real-world effort to implement guidelines for a hospital-based cessation service consistent with Joint Commissions standards. Between February 2014 and May 2015, 42 061 adults were admitted to the Medical University of South Carolina Hospital. Eligible current cigarette smokers were referred to the tobacco-cessation service, which consisted of a bedside consult and phone follow-up 3, 14, and 30 days after hospital discharge using interactive-voice-response. The primary study outcomes evaluated the proportions of smokers reached by the bedside counselor and/or phone follow-up, smokers who opted out, and smokers who self-reported not smoking when last contacted by phone.nnnResultsnRecords identified 8423 smokers, of whom 69.4% (n = 5843) were referred into the service. One full-time bedside counselor was able to speak with 1918 (32.8%) patients, of whom 96 (5%) denied currently smoking and 287 (14.9%) refused counselling. Reach at follow-up was achieved for 703 (55%) smokers who received bedside counselling and 1613 (49%) who did not, yielding an overall follow-up reach rate of 60%. Of those reached by phone, 36.4% reported not smoking (51% vs. 27% for those who did and did not receive bedside counselling, respectively). Intent-to-treat abstinence rate was 13.5% according to the last known smoking status.nnnConclusionsnFindings from this study suggest that an inpatient smoking-cessation service with an opt-out approach can positively impact short-term cessation outcomes.nnnImplicationsn(1) The findings demonstrate the feasibility of implementing an automated large-scale opt-out tobacco-cessation service for hospitalized patients that is consistent with the Joint Commission recommended standards for treating tobacco dependence. (2) Receiving a bedside tobacco-cessation consult while hospitalized increased the use of stop smoking medications and abstinence from smoking after discharge from the hospital. (3) Even in those patients who did not receive a bedside consult, 5% accepted a referral to the South Carolina Tobacco Quitline to get help to stop smoking.

A Multicomponent Intervention Including Texting to Promote Tobacco Abstinence in Emergency Department Smokers: A Pilot Study

BACKGROUNDnEmergency department (ED) patients commonly smoke. Current treatment approaches use motivational interviewing, which is effective, but resource-intensive. Mobile health approaches may be more feasible and generalizable.nnnOBJECTIVEnThe objective was to assess the feasibility of an ED-initiated program of tobacco dependence treatment that employs text messaging.nnnMETHODSnSmokers age 18 or older were randomized to intervention or control arms. Control subjects received a brochure describing the state smokers quitline. Intervention subjects received the brochure, 4 weeks of nicotine patches and gum (with the initial dose administered in the ED), a referral to the quitline, and enrollment in SmokefreeTXT, a free SMS-messaging service. SmokefreeTXT delivered 28 days of messages, two to five messages/day. Some messages ask subjects to provide data on mood or craving. Follow-up was conducted by phone call.nnnRESULTSnSixty subjects were enrolled in May 2014. Of all subjects, 33 (55%) were nonwhite; 78% were insured by Medicaid. All intervention subjects used the texting program, with 24/30 (80%) using the program for all 28 days. At 1 month, 14/30 subjects (47%) in the intervention arm reported abstinence versus 3/30 (10%) in the control arm (p = 0.003). At 3 months, the abstinence rates in the intervention and control arms were, respectively, 9/30 (30%) and 4/30 (13%; p = 0.21). Subjects responding to more assessments of mood or craving were more likely to report abstinence at 1 month.nnnCONCLUSIONnA texting program, combined with pharmacotherapy and a quitline referral, is feasible and may promote tobacco abstinence in ED smokers. A larger trial is planned to assess these results.

Cognitive testing of tobacco use items for administration to patients with cancer and cancer survivors in clinical research

To the authors knowledge, there are currently no standardized measures of tobacco use and secondhand smoke exposure in patients diagnosed with cancer, and this gap hinders the conduct of studies examining the impact of tobacco on cancer treatment outcomes. The objective of the current study was to evaluate and refine questionnaire items proposed by an expert task force to assess tobacco use.

Tobacco Dependence Predicts Higher Lung Cancer and Mortality Rates and Lower Rates of Smoking Cessation in the National Lung Screening Trial

BACKGROUND: Incorporating tobacco treatment within lung cancer screening programs has the potential to influence cessation in high‐risk smokers. We aimed to better understand the characteristics of smokers within a screening cohort, correlate those variables with downstream outcomes, and identify predictors of continued smoking. METHODS: This study is a secondary analysis of the National Lung Screening Trial randomized clinical study. Tobacco dependence was evaluated by using the Fagerström Test for Nicotine Dependence, the Heaviness of Smoking Index, and time to first cigarette (TTFC); descriptive statistics were performed. Clinical outcomes (smoking cessation, lung cancer, and mortality) were assessed with descriptive statistics and χ2 tests stratified according to nicotine dependence. Logistic and Cox regression models were used to study the influence of dependence on smoking cessation and mortality, respectively. RESULTS: Patients with high dependence scores were less likely to quit smoking compared with low dependence smokers (TTFC OR, 0.50 [95% CI, 0.42–0.60]). Indicators of high dependence, as measured according to all three metrics, were associated with worsening clinical outcomes. TTFC showed that patients who smoked within 5 min of waking (indicating higher dependence) had higher rates of lung cancer (2.07% for > 60 min after waking vs 5.92% ≤ 5 min after waking; hazard ratio [HR], 2.56 [95% CI, 1.49–4.41]), all‐cause mortality (5.38% for > 60 min vs 11.21% ≤ 5 min; HR, 2.19 [95% CI, 1.55–3.09]), and lung cancer‐specific mortality (0.55% for > 60 min vs 2.92% for ≤ 5 min; HR, 4.46 [95% CI, 1.63–12.21]). CONCLUSIONS: Using TTFC, a one‐question assessment of tobacco dependence, at the time of lung cancer screening has implications for personalizing tobacco treatment and improving risk assessment.

Design and implementation of decision support for tobacco dependence treatment in an inpatient electronic medical record: a randomized trial.

Tobacco dependence treatment for hospitalized smokers results in long-term cessation if treatment continues at least 30xa0days post-discharge. Health information technology may facilitate ongoing tobacco dependence treatment after hospital discharge. To describe the use and impact of a new decision support tool and order set for inpatient physicians, addressing tobacco dependence treatment for hospitalized smokers, embedded in an electronic health record (EHR). In a cluster-randomized trial, 254 physicians were randomized (1:1) to either receive or not receive the decision support tool and order set, which were embedded in the Epic (Madison, WI) EHR used at 2 hospitals in a single city. When an adult patient was admitted to a medical service, an electronic alert appeared if the patient was coded in the EHR as a smoker. For physicians randomized to the intervention, the alert linked to an order set to prescribe tobacco treatment medications and refer the patient to the state tobacco quitline. Additionally, “tobacco use disorder” was added to the patient’s problem list, and an e-mail was sent to the patient’s primary care provider (PCP). In the control arm, an alert fired with no screen visibility. Generalized estimating equations were used to model the data. Since August 2013, the alert has appeared for 10,939 patients (5391 intervention, 5548 control). Compared to control physicians, intervention physicians were more likely to order tobacco treatment medication (35 vs. 29%, Pxa0<xa00.0001), populate the problem list with tobacco use disorder (41 vs. 2%, Pxa0<xa00.0001), and make a referral to the state smokers’ quitline (30 vs. 0%, Pxa0<xa00.0001). In addition, intervention physicians sent an e-mail to the patient’s PCP 4152 (99%) times. Designing and implementing an order set and alert for tobacco treatment in an EHR is feasible and helps physicians place more orders for tobacco treatment medication, referrals to the state smokers’ quitline, and e-mails to patients’ PCPs. Data on cessation outcomes are pending. Trial registration: www.ClinicalTrials.gov (NCT01691105).