Surprisingly few smoking intervention studies with cancer patients have been conducted. One study found that when consistent intervention was provided to a group of head and neck cancer patients, about 65% were able to quit and remain abstinent, including about half of those who expressed little interest in quitting at baseline.[1] A large intervention study with head and neck cancer patients used surgeon- or dentist-delivered advice to stop smoking, contracted quit dates, written materials, and booster advice sessions. Partially because of a high drop-out rate, a significant intervention effect was not detected, though differences were in the expected direction.[1] A similar study [2] also failed to find beneficial effects for very brief (<5 minutes) physician-delivered interventions based on the Ask, Advise, Assist, Arrange model outlined below. More than 400 cancer patients with a range of diagnoses were randomly assigned to receive either intervention or usual care. Approximately half had been diagnosed within the previous 6 months, 46.3% had tried to quit in the previous 6 months, and 84% were considering quitting in the following 6 months. Patients randomly assigned to the intervention group acknowledged receiving advice and resources from their physician consistent with the protocol; however, there were no significant differences in quit rates at either 6-month follow-up (11.9% vs. 14.4%) or 12-month follow-up (13.6% vs. 13.3%). Patients were more likely to quit smoking if they had been diagnosed with head and neck cancer or lung cancer, were lighter smokers, expressed a strong desire to quit, and used additional intervention resources. These results suggest that very brief physician counseling for this high-risk group is not adequate to improve quit rates.

A case-controlled retrospective study [3] examined the effects of referral to a nicotine dependence center for more than 200 smokers diagnosed with lung cancer compared with smokers without a lung cancer diagnosis. Most lung cancer patients were less likely to have made previous attempts to quit but expressed higher motivation to quit smoking than did individuals without lung cancer. Although the likelihood of being abstinent at 6 months postintervention was higher among lung cancer patients (22% vs. 14%), after adjusting for demographic variables and level of motivation, there was no statistically significant difference. Patients who were closer to diagnosis at the time of intervention were far more likely to be abstinent at 6 months (27.3% vs. 0% for 3–6 months vs. 7% for >6 months, P = .01). In general, a brief smoking intervention consisting of approximately 1 hour of tailored intervention, including prescription of pharmacologic treatment, showed relatively little impact in this high-risk population. However, referral sooner after diagnosis may increase the likelihood of quitting. This study is limited by the self-selection of patients and lack of a nonintervention comparison group.

Considerable work has been done, however, with other patient groups—particularly cardiac patients—establishing the valuable role of physicians and other health care providers in providing smoking intervention in the context of medical care. Specific recommendations for intervening in tobacco use have been published in several contexts. On the basis of outcomes from six major clinical trials of physician-delivered smoking intervention conducted in the late 1980s,[4] the Ask, Advise, Assist, Arrange model was developed. In this model, the physician provides a brief intervention that entails asking about smoking status at every visit, advising abstinence, assisting by setting a quit date, providing self-help materials and recommending use of nicotine replacement therapy, and arranging for a follow-up visit. See the list below for brief and expanded intervention outlines. The Patient-Centered Counseling Key Elements list below provides detailed questions that may be asked in the assist phase in a patient-centered counseling format that is brief enough (5–7 minutes) to be delivered within the context of a usual office visit.[5]

These recommendations form the core of the Public Health Service–sponsored Clinical Practice Guideline [6,7] that extended the recommendations by strongly supporting the value of referral to more intensive counseling. Furthermore, in addition to the documented value of nicotine replacement therapy (using gum, lozenge, patch, nasal spray, or inhaler), there is now clear evidence for the value of the antidepressant bupropion HCl (Wellbutrin SR and Zyban), 150 mg twice a day, as an adjunct for treatment;[8] however, these adjunctive pharmacological treatments have not been tested in cancer patients. Individuals should be advised to check with their physicians.

Not all smokers are equally motivated to stop smoking. One of the most useful models for physicians in understanding the motivational issues in stopping smoking and actually quitting is the Stages of Change Model. Most individuals attempting to change a complex behavior such as smoking go through several predictable stages, from precontemplation to contemplation to preparation and finally action. One of the goals of brief physician counseling is to move patients along these stages, until they are more motivated to quit. In addition, especially for first-time quitters, relapsing and cycling through these stages one or more times is common, until the person develops better behavioral skills. The most common triggers for relapse are stressful situations and social triggers for smoking. One study found that the patterns of relapse in head and neck cancer patients were comparable to patterns of relapse in quitters in the general population.[9] Smokers should be encouraged to anticipate such situations and develop strategies for handling them, as part of developing a new identity as a nonsmoker. It may take more than a year for even motivated smokers to successfully make these changes. The Stages of Change Model is well described and summarized [6] and is outlined as part of the Ask, Advise, Assist, Arrange Key Elements list below. Other important information such as smoking history (e.g., amount smoked or previous attempts to quit) can be efficiently collected by asking patients to complete a brief set of self-assessment forms in the waiting room. Nicotine addiction can be assessed using the Fagerstrom Test for Nicotine Addiction, and behavioral patterns (e.g., tendency to smoke when under stress) can be assessed using the Online Guide to Quitting.

Tailoring intervention for specific populations may also be important, although this has not been examined specifically in cancer patients. A study of the effects of self-help intervention materials designed for an African American population showed higher quit rates (25%) among those receiving the tailored materials than among those receiving the standard materials (15.4%) at 12 months postintervention.[10]

Other investigators have begun to examine intervention approaches specific to patients at high risk for developing lung cancer, through the use of genetic biomarker feedback (presence of the CYP2D6 genetic abnormality, which increases the risk of developing lung cancer twofold to fourfold) in otherwise healthy smokers. Adding information on genetic risk for cancer to the usual counseling approaches increased initial quit rates significantly, but this effect was not maintained; such an approach may be a useful motivational component to add to a more comprehensive intervention but may not be sufficient in itself.[11]

Ask, Advise, Assist, Arrange Key Elements

1. Ask/Assessment:
   • Minimal assessment: Screen for smoking status at every visit or admission.
   
   
   
   • Augmented assessment: Assess characteristics of smoking history and patterns.
     • Amount smoked.
     • Quit history.
     • Stage of change:
       • Precontemplator: Is not seriously considering stopping smoking.
       • Contemplator: Is seriously considering stopping within 3 to 6 months.
       • Preparation: Is seriously considering stopping within the next week to month, and has already made changes such as cutting back.
       • Action: Has recently stopped smoking (within last 6 months).
       • Relapse: Has quit for at least 48 hours but is smoking again.
       • Maintenance: Has quit for at least 6 months but may still be vulnerable to a relapse up to 1 year.
   
   
   
   • Nicotine addiction: Fagerstrom Test for Nicotine Addiction.
   
   
   
   • Behavioral patterns: Online Guide to Quitting.
   
   
   



2. Advise:
   • Minimal advice: “As your physician, I must advise you that smoking is bad for your health, and it would be important for you to stop.”
   
   
   
   • Augmented advice: “Because of your (__________) condition, it is particularly important for you to stop. If you stop now, (briefly educate patient about basic health benefits from quitting).”
   
   
   



3. Assist/Counsel:
   • Minimal assistance: Provide self-help materials; assess interest in quitting; assess interest in and appropriateness of pharmacological aids.
   
   
   
   • Augmented assistance: Provide brief 5- to 7-minute patient-centered counseling. See the list below for an outline of the counseling content.
   
   
   



4. Arrange follow-up support:
   • Minimal follow-up support: Arrange for single follow-up contact by visit or by telephone in about 2 weeks; provide referral to a smoking counselor or group.
   
   
   
   • Extended follow-up support: Establish quit-smoking contract with quit date. Arrange three or more follow-up contacts by visit or by telephone.
   
   
   

Patient-Centered Counseling Key Elements

1. Motivation:
   • Basic question:
     • “How do you feel about your smoking?”
   • Follow-up questions:
     • “How do you feel about stopping smoking?”
     • “Have you ever tried to stop before?” “What happened?”
     • “What do you like about smoking?”
     • “What do you not like about smoking?”



2. Anticipated problems:
   • Basic question:
     • “What problems will you have if you stop smoking?”
   • Follow-up questions:
     • “Anything else?”
     • According to your Craving Journal (available through the Online Guide to Quitting), your craving level was highest when you were (_____). How do you think you can handle that type of situation?”



3. Resources for coping with problems
   • Basic question:
     • “How do you think you can handle that?”
   • Follow-up questions:
     • “What else could you do?”
     • “How do you expect your (family/spouse/friends) to help you?”

References

1. Gritz ER, Carr CR, Rapkin D, et al.: Predictors of long-term smoking cessation in head and neck cancer patients. Cancer Epidemiol Biomarkers Prev 2 (3): 261-70, 1993 May-Jun.  [PUBMED Abstract]
   
   
2. Schnoll RA, Zhang B, Rue M, et al.: Brief physician-initiated quit-smoking strategies for clinical oncology settings: a trial coordinated by the Eastern Cooperative Oncology Group. J Clin Oncol 21 (2): 355-65, 2003.  [PUBMED Abstract]
   
   
3. Sanderson Cox L, Patten CA, Ebbert JO, et al.: Tobacco use outcomes among patients with lung cancer treated for nicotine dependence. J Clin Oncol 20 (16): 3461-9, 2002.  [PUBMED Abstract]
   
   
4. Glynn TJ, Manley MW, Pechacek TF: Physician-initiated smoking cessation program: the National Cancer Institute trials. Prog Clin Biol Res 339: 11-25, 1990.  [PUBMED Abstract]
   
   
5. Ockene JK, Kristeller J, Goldberg R, et al.: Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial. J Gen Intern Med 6 (1): 1-8, 1991 Jan-Feb.  [PUBMED Abstract]
   
   
6. Prokhorov AV, Hudmon KS, Gritz ER: Promoting smoking cessation among cancer patients: a behavioral model. Oncology (Huntingt) 11 (12): 1807-13; discussion 1813-4, 1997.  [PUBMED Abstract]
   
   
7. Fiore MC, Bailey WC, Cohen SJ, et al.: Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, Md: Public Health Service, U.S. Department of Health and Human Services, 2000. Also available online. Last accessed February 17, 2009. 
   
   
8. Cinciripini PM, McClure JB: Smoking cessation: recent developments in behavioral and pharmacologic interventions. Oncology (Huntingt) 12 (2): 249-56, 259; discussion 260, 265, 2, 1998.  [PUBMED Abstract]
   
   
9. Gritz ER, Schacherer C, Koehly L, et al.: Smoking withdrawal and relapse in head and neck cancer patients. Head Neck 21 (5): 420-7, 1999.  [PUBMED Abstract]
   
   
10. Orleans CT, Boyd NR, Bingler R, et al.: A self-help intervention for African American smokers: tailoring cancer information service counseling for a special population. Prev Med 27 (5 Pt 2): S61-70, 1998 Sep-Oct.  [PUBMED Abstract]
    
    
11. Audrain J, Boyd NR, Roth J, et al.: Genetic susceptibility testing in smoking-cessation treatment: one-year outcomes of a randomized trial. Addict Behav 22 (6): 741-51, 1997 Nov-Dec.  [PUBMED Abstract]
    
    

Back to Top

< Previous Section  |  Next Section >