Smoking cessation care can translate to lower hazard of death in the short-run in cancer patients - a retrospective cohort study to demonstrate the value of smoking cessation services within the treatment phase of cancer

Cancer Care in Resource-Limited Countries: Jordan as an Example

Jordan, a lower- to middle-income country, is relatively small, but with rapidly growing population and a challenged economy. Cancer is a growing health care problem and currently ranked second, after cardiovascular diseases, as a cause of death. Jordan's national cancer registry continues to suffer from problems mostly related to long lag time in reporting, absence of outcome data, and accurate staging. The number of new patients with cancer diagnosed in Jordan is increasing at an expected, none disturbing rate, fueled by population growth, improving life expectancy, changing population structure that hosts more older population, high rate of obesity, smoking, and lack of adequate exercise. However, age-standardized rate for cancer incidence is significantly lower than Western societies, yet, mortality rate is higher. Despite efforts, cancer is still diagnosed at more advanced stages and at younger age. The Jordan breast cancer program represents a great example of opportunistic screening that led to significant downstaging of breast cancer. Efforts to evaluate the feasibility of screening programs for colorectal and lung cancers are underway. Tremendous efforts resulted in the execution of the largest clinical cancer genetics program in the region that helps identify patients and at-risk relatives for hereditary cancers. Low-resourced countries, including Jordan, will not be able to keep up with the rapidly increasing cost of cancer care. A better access to clinical trials and moving cancer care to ambulatory settings should offset some of this cost. A cancer control program that addresses all issues of cancer care from screening and early detection, through active cost-effective treatment that assures wider access to palliative care, hospice, and survivorship programs under an expanded universal health coverage, is an urgent national health priority.

Physician-brief advice for promoting smoking cessation among cancer patients on treatment in low and middle-income countries: a scoping review

INTRODUCTION

Physician-brief advice has been utilized in high-income countries to promote smoking cessation among cancer patients. Empirical evidence on its effectiveness among cancer patients in low and middle-income countries (LMICs) is lacking. The gap could be due to inadequate training, and competing healthcare priorities, leading to insufficient implementation of targeted smoking cessation interventions in oncology settings. We undertook this scoping review to determine if physician-brief advice is effective in promoting smoking cessation among cancer patients in LMICs.

METHODS

We conducted a literature search of all relevant articles across five databases: Cochrane Central Register of Controlled Trials, Cochrane Library (Tobacco Addiction Group trials), World Conference on Lung Cancer proceedings, PubMed, and Google Scholar up to November 2023, using pre-defined inclusion criteria and keywords. The study population was cancer survivors in LMICs, the intervention was smoking cessation advice by a physician in a clinic or oncology center during a consultation, and the outcome was the effect of smoking cessation programs in discontinuing smoking among cancer survivors in LMICs.

RESULTS

Overall, out of every 10 cancer patients in LMICs, about seven were smokers, and one-half had received physician-brief advice for smoking cessation. Physician-brief advice was more likely to be delivered to patients with smoking-related cancer (Cohen's d = 0.396). This means that there is a noticeable difference between patients with smoking-related cancer compared to those with cancer unrelated to smoking. Smoking cessation failure was due to the inability to cope with the symptoms of withdrawal, missed smoking cessation clinic visits, mental health disorders, limited time and resources, and minimal patient-physician contact.

CONCLUSION

There is very little literature on the frequency of use or the efficacy of physician-brief advice on smoking cessation in LMICs. The literature suggests that cancer patients in LMICs have low self-efficacy to quit smoking, and smoking cessation is rarely part of cancer care in LMICs. Physicians in LMICs should be trained to use motivational messages and good counseling techniques to improve smoking cessation among cancer patients. Policymakers should allocate the resources to implement physician-brief advice and design training programs for physicians focusing on physician-brief advice tailored to cancer patients.

Oncology Patient Smoking Cessation Treatment Preferences: Perceptions Across Former and Current Cigarette Smokers

Although the benefits of smoking cessation following a cancer diagnosis have been well-established, up to 50% of cancer patients continue to smoke. Continued smoking through oncology treatment leads to increased risk of adverse events including reduced effectiveness of treatment, recurrence of additional malignancies, and reduced survival rates. Upon the cancer diagnosis, oncology healthcare providers become the primary trusted source of information and support, which represents a great opportunity to assist these patients to quit smoking. However, it remains unclear how oncology healthcare providers can best address smoking cessation from a patient-centered perspective. The present study surveyed oncology patients from Birmingham, AL, classified as either former (n = 174) or current smokers (n = 81) to identify their perceptions regarding the role of oncology healthcare providers in their smoking cessation efforts. Current smokers were more likely to be younger, received their cancer diagnosis within the past 3 years, and have a cancer diagnosis with high smoking-related public awareness (i.e., head, neck, or lung) compared to former smokers. Additionally, 81% of current smokers reported experiencing smoking cessation discussions with their oncology healthcare providers with the most prominent recommendations being use of nicotine replacement therapies (46.9%) and medication (35.8%). These smoking cessation experiences align with patient preferences. However, despite the frequency of smoking cessation discussions, current smokers demonstrated an ambivalence in understanding the risks of continued smoking during their medical treatment. Overall, this study highlights the important role of oncology healthcare providers on implementing smoking cessation intervention for their patients who continue to smoke.

Treating Smoking in Cancer Patients: An Essential Component of Cancer Care-The New National Cancer Institute Tobacco Control Monograph

PURPOSE

Continued smoking after the diagnosis of cancer can markedly worsen oncology treatment side effects, cancer outcomes, cancer mortality, and all-cause mortality. Conversely, mounting evidence demonstrates that smoking cessation by patients with cancer improves outcomes. A cancer diagnosis often serves as a teachable moment, characterized by high motivation to quit. However, too few patients with cancer who smoke are offered evidence-based smoking cessation treatment, and too few engage in such treatment.

METHODS AND MATERIALS

The National Cancer Institute commissioned Tobacco Control Monograph 23, Treating Smoking in Cancer Patients: An Essential Component of Cancer Care, to review and synthesize the evidence that clarifies the need to intervene with smoking in cancer care.

RESULTS

Although many patients with newly diagnosed cancer who smoke make quit attempts, many of these are unsuccessful, and among those who successfully quit, relapse is common. Indeed, an estimated 12.2% of adults ever diagnosed with cancer reported they currently smoked (National Health Interview Survey, 2020). Patients with cancer who smoke are likely to benefit from smoking cessation treatments, including counseling and US Food and Drug Administration-approved medications, and there are many effective strategies to increase delivery of smoking cessation treatment in cancer care settings.

CONCLUSION

Smoking cessation is among the most effective treatment options for improving the likelihood of survival, quality of life, and overall health of patients with cancer who smoke. It is important for cancer care clinicians and patients to realize that it is never too late to quit smoking and that there are clear benefits to doing so, regardless of cancer type.

Supporting Smokers in Difficult Settings: Suggestions for Better Education and Counseling in Cancer Centers in Jordan

Continued smoking in cancer patients is commonly observed in Jordan. In a country that exhibits some of the highest smoking rates globally, enhancing patient education regarding the value of smoking cessation for cancer care is vital. The objectives of our study were to describe sociodemographic and clinical factors associated with continued smoking in Jordanian smokers after a cancer diagnosis; to identify reasons for smoking and knowledge regarding smoking's impact on care; to examine in a multivariable manner the factors associated with continued smoking, and to accordingly generate patient counseling recommendations. An interviewer-administered survey using the Theoretical Domains Framework was employed. Among 350 subjects (mean age 51.0, median 52.7), approximately 38% of patients had quit or were in the process of quitting; 61.7% remained smokers. Substantial knowledge gaps with regard to the impact of continued smoking on cancer care were observed. Remaining a smoker after diagnosis was associated with being employed, not receiving chemotherapy or surgery, having lower confidence in quitting, and having a lower number of identified reasons for smoking. Interventions to promote cessation in Jordanian cancer patients who smoke should focus on enhancing patient awareness about the impact of smoking in cancer care and raising perceived self-efficacy to quit.

Cessation experiences and quitting perspectives of Jordanian cancer patients who smoke

OBJECTIVES

To describe quitting experiences of cancer patients in a Cancer Center in Jordan; to study patients' perceptions regarding the process of smoking cessation; and to provide insights about patients in this difficult setting in order to inform oncology practitioners with regards to how improve perceptions and skills related to quitting.

METHODS

An Arabic cross-sectional questionnaire was developed to evaluate smoking and quitting behaviors in the context of cancer. The tool used as its framework the Theoretical Domains Framework to capture quitting perceptions of cancer patients who smoke, as well as social, environmental, and system-level factors that influence quitting. Eligible patients who were treated at the Center (both in-patient and out-patient settings) and who were current smokers or who smoked up to the time of cancer diagnosis were eligible. Patients were interviewed between July, 2018 and January 2020 using two versions of the questionnaire: an 'ex-smokers' version, and a 'current smokers' version.

RESULTS

Only a third of subjects (104/350) had been smoke-free for at least 30 days. Both smokers and ex-smokers generally felt that quitting was important, but mean importance and confidence scores (out of 10) were significantly lower in current smokers (8.2 versus 9.1, p-value=0.002; 6.4 versus 8.7, p-value=0.000). Roughly 31% of subjects believed smoking harms were exaggerated and that smoking was not an addiction. About 62% of subjects agreed quitting required skills, and 78.5% felt the steps to quit were clear, but across several listed strategies for quitting, use of these was limited (even in ex-smokers). Among current smokers, roughly a third exhibited forms of cessation fatigue.

CONCLUSION

Jordanian cancer patients who smoke present with limited knowledge about the quitting process. Even when some success is observed, low rates of utilization of specific quitting strategies were observed, highlighting the need for better counseling about quitting.

Country profile: Australia, New South Wales. From validation to implementation: Progressing tobacco smoking cessation among people with cancer and beyond via relevant authorities

This paper delineates how a program of tobacco smoking cessation after a cancer diagnosis was achieved by engagement of multiple stakeholders, government, and non-government authorities in one jurisdiction in Australia, New South Wales. While it had become increasingly obvious that smoking cessation imparts benefits akin to other known treatment modalities, knowledge of this generalisation is without benefit unless this information is delivered in a trusted context and means to quit are made available. Against a backdrop of little enthusiasm among clinicians, the Cancer Institute NSW, charged with implementing tobacco control strategies, decided to focus its 2017 annual colloquium on the topic. While the evidence was unequivocal, better clarity was needed that this was indeed a clinical responsibility, and on the resources needed. The Clinical Oncology Society of Australia, (COSA) a non-governmental peak national body representing cancer care professionals, addressed this challenge. The society's governing body resolved to develop a position statement indicating how smoking cessation might be integrated within hospital-based cancer care. The position statement, endorsed by nineteen other cancer and non-cancer organisations, provided reassurance to the Institute to improve record capture of hospital smoking information; upskill all clinical staff and develop an automatic "patient opt out" referral to existing resources such as the Quitline. Early pilot work shows that people newly diagnosed with cancer who smoke and who were advised at that time to quit increased from 55% in 2016 to 72% in 2019.

Responses of smoking and nonsmoking cancer patients to drug treatment: A protocol for systematic review and meta-analysis

INTRODUCTION

Smoking is well-known to increase cancer risk, particularly risk of lung cancer, and negatively affects efficacy of cancer treatment. However, recent evidence suggests that among cancer patients, paradoxically, smokers respond to treatment better than non-smokers. We propose to conduct a focused review and meta-analysis to compare response to drug treatment between smoking and non-smoking cancer patients.

METHODS AND DESIGN

We will collect data from large clinical trials of therapies for cancer patients which have included smokers and non-smokers. We will search PubMed, PMC/ MEDLINE, SCOPUS, Embase, and the registries for clinical trials and four major clinical journals up to June 30, 2019. Search terms will be "Drug name" phase-3" or "Drug name" phase-III." Data collection will be focused on randomized clinical trials of cancer drugs that enrolled at least 100 participants and reporting treatment results from smoking and nonsmoking patients. Initial selection criteria will be clinical trial studies of drug treatment of 100 or more cancer patients, and reporting hazard ratios (HR) for smokers and non-smokers. Two persons will be searching such publications independently, or data will be provided, double checked, or confirmed by authors. Multiple sub-group analyses will be conducted by at least two persons to avoid bias or experimental errors.

DISCUSSION

The results will clarify whether smoking and response to treatment of cancer are linked not. Our results may possibly identify drug/s that work better among cancer patients who are smokers.

TRIAL REGISTRATION

PROSPERO registration number: CRD42019146402.

Smoking cessation and survival among people diagnosed with non-metastatic cancer

Background

We aimed to estimate the effects of smoking cessation on survival among people diagnosed with cancer.

Methods

We used data from a Comprehensive Community Cancer Program that is part of a large urban safety-net hospital system. Eligible patients were diagnosed with primary invasive solid tumors between 2013 and 2015, and were current smokers at time of diagnosis. Our exposure of interest was initiation of smoking cessation within 6 months of cancer diagnosis. We estimated inverse probability weighted restricted mean survival time (RMST) differences and risk ratio (RR) for all cause 3-year mortality.

Results

Our study population comprised 369 patients, of whom 42% were aged < 55 years, 59% were male, 44% were racial/ethnic minorities, and 59% were uninsured. The 3-year RMST was 1.8 (95% CL: − 1.5, 5.1) months longer for individuals who initiated smoking cessation within 6 months of cancer diagnosis. The point estimate for risk of 3-year mortality was lower for initiation of smoking cessation within 6 months of diagnosis compared with no initiation within 6 months (RR = 0.72, 95% CL: 0.37, 1.4).

Conclusions

Our point estimates suggest longer 3-year survival, but the results are compatible with 1.5 month shorter or 5.1 longer 3-year overall survival after smoking cessation within 6 months of cancer diagnosis. Future studies with larger sample sizes that test the comparative effectiveness of different smoking cessation strategies are needed for more detailed evidence to inform decision-making about the effect of smoking cessation on survival among cancer patients.

Implications for Cancer survivors

The benefits of smoking cessation after cancer diagnosis may include longer survival, but the magnitude of benefit is unclear.

Design and Pilot Implementation of an Electronic Health Record-Based System to Automatically Refer Cancer Patients to Tobacco Use Treatment

Continued tobacco use after cancer diagnosis is detrimental to treatment and survivorship. The current reach of evidence-based tobacco treatments in cancer patients is low. As a part of the National Cancer Institute Cancer Center Cessation Initiative, the Mayo Clinic Cancer Center designed an electronic health record (EHR, Epic^©)-based process to automatically refer ambulatory oncology patients to tobacco use treatment, regardless of intent to cease tobacco use(“opt out”). The referral and patient scheduling, accomplished through a best practice advisory (BPA) directed to staff who room patients, does not require a co-signature from clinicians. This process was piloted for a six-week period starting in July of 2019 at the Division of Medical Oncology, Mayo Clinic, Rochester, MN. All oncology patients who were tobacco users were referred for tobacco treatment by the rooming staff (n = 210). Of these, 150 (71%) had a tobacco treatment appointment scheduled, and 25 (17%) completed their appointment. We conclude that an EHR-based “opt-out” approach to refer patients to tobacco dependence treatment that does not require active involvement by clinicians is feasible within the oncology clinical practice. Further work is needed to increase the proportion of scheduled patients who attend their appointments.