Nick Mulcahy

March 30, 2017

ORLANDO, Florida – Paul Cinciripini, PhD, a clinical psychologist at the MD Anderson Cancer Center in Houston, Texas, said, "[I've] spent the better part of my life dedicated to...helping people to stop smoking."

Speaking here at the National Comprehensive Cancer Network (NCCN) 22nd Annual Conference, Dr Cinciripini encouraged oncologists to work with cancer patients who smoke, given the multitude of benefits that come with cessation, including improved survival.

Currently, the odds that a smoker of any health status will successfully quit are not high. Annually, fewer than 10% of those who attempt to quit succeed, he pointed out.

With the challenging goal of cessation in mind, Dr Cinciripini provided the meeting attendees with a series of insights about smoking, smokers, and quitting that may help clinicians help their patients overcome the odds.

Smoking and mental illness have a "strong connection." About one third of all cigarettes in the United States are smoked by adults with mental illness. And 40% of men and 34% of women with mental illness smoke, said Dr Cinciripini, who is a member of the NCCN smoking cessation panel, which was established last year, as reported by Medscape Medical News.

He also said that across all age groups, higher levels of psychological distress, such as depression and anxiety, are associated with smoking.

Dr Cinciripini pointed out that clinicians, in having discussions with their patients, should seek to understand the emotional needs in which "nicotine dependence is rooted." Long-term use of nicotine can be "depressogenic," he also observed.

"The good news is that things get better when people stop," he said. The effect size of quitting smoking among depressed people is as large as that for antidepressant pharmacologic treatment.

Smoking is most common among the most vulnerable and those with the least resources. Smoking prevalence rates in the United State have been coming down for the past 20 to 30 years, but numbers are "deceptive" because of disparities among groups, said Dr Cinciripini. Data about smokers and level of education (ie, socioeconomic status) reveal that only 3% of Americans with postgraduate degrees smoke vs 24% to 34% of those with a high school education or less. These numbers reveal that smoking may be tied to insecurity and stress, he suggested.

Another smoking cessation expert acknowledged the important tie between smoking and stress. "Smoking serves unique functions for individuals, such as contributing to stress management and that patients will need help and practice managing without smoking," said Christine Sheffer, PhD, a clinical psychologist at Roswell Park Cancer Institute in Buffalo, New York, who was asked for comment.

Relapsing is the "norm" because nicotine dependence is a chronic, relapsing disorder. "It's not like we are treating infectious disease," said Dr Cinciripini, adding that clinicians "can't just make it go away" with treatment. As a result, there is a need to continually present opportunities for treatment to cancer patients who smoke, he said. But if clinicians do not address a patient's mood and the potential for affective withdrawal symptoms, such anger or anxiety, then a big component of the smoking habit is missed, he further commented.

After assessing a patient's willingness to quit, clinicians should encourage smoking reduction in those who are not ready for cessation, said Dr Cinciripini. "Cessation is an ongoing effort," he said. "It's not one and done."

Most smokers want to quit. According to surveys, roughly 70% of smokers want to quit, said Dr Cinciripini. About 55% report a quit attempt (abstention for at least 24 hours) in the past year. But the success rate is low — among smokers who try to quit annually, fewer than 8% succeed, as noted above.

Benefits galore with cessation for cancer patients. In a 2016 study in lung cancer patients who underwent stereotactic body radiation therapy for lung cancer, those patients who quit smoking had a significantly better overall survival at 2 years than those who continued to smoke (78% vs 69%; P = .01) "It's a really tangible reason to talk about smoking cessation with patients," said Dr Cinciripini about the survival benefit.

Research has also shown that among cancer patients, stopping smoking improves the likelihood of successful cancer treatment and is associated with fewer and less severe side effects, as reported recently for radiotherapy in breast cancer. It is also tied to faster recovery, decreased risk for secondary cancers, and lower risk for infection. Plus, it makes for easier breathing, provides more energy, and improves quality of life.

Cancer patients may not know about these benefits, so counseling may also help dispel "fatalism" about their disease, said Dr Sheffer.

Both counseling and medications should be offered. The more counseling, the better, said Dr Cinciripin. He explained that increasing the intensity of counseling increases the possibility of cessation. In general, the NCCN recommends combining pharmacotherapies with counseling.

Per the NCCN guidelines, in terms of pharmacotherapy, in the first line, combination nicotine replacement therapy (NRT) is recommended (nicotine patch plus a short-acting lozenge, gum, inhaler, or nasal spray). The other option is varenicline (Chantix, Pfizer).

In the second line, two combinations are suggested: either varenicline plus NRT, or bupropion plus NRT.

In the third line, options include nortriptyline (a tricyclic antidepressant) and clonidine, an alpha-2 adrenergic receptor agonist used to treat hypertension.

About these latter options, Dr Cinciripin said, "Quite frankly, we never use them."

e-Cigarettes, which deliver nicotine in vapors, are not recommended as aides to cessation because the evidence of their efficacy is insufficient, he added. "But I'm not ruling it out," he said. After all, NRTs, such as gum, are recommended, he pointed out. Also, carcinogens are drastically reduced or eliminated in e-cigarettes.

Dr Cinciripini and Dr Sheffer have disclosed no relevant financial relationships.

National Comprehensive Cancer Network (NCCN) 22nd Annual Conference. Presented March 25, 2017.

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