Successes and failures of the teachable moment

Successes and Failures of the Teachable MomentSmoking Cessation in Cancer Patients

Ellen R. Gritz, Ph.D.1

Michelle Cororve Fingeret, Ph.D.1

Damon J. Vidrine, Dr.P.H.1

Amy B. Lazev, Ph.D.2

Netri V. Mehta, M.P.H.3

Gregory P. Reece, M.D.4

1 Department of Behavioral Science, The Universityof Texas M.D. Anderson Cancer Center, Houston,Texas.

2 Division of Population Science, Psychosocial andBehavioral Medicine Program, Fox Chase Cancer,Cheltenham, Pennsylvania.

3 The University of Texas Health Science Center,School of Public Health, Houston, Texas.

4 Department of Plastic Surgery, The University ofTexas M.D. Anderson Cancer Center, Houston,Texas.

Address for reprints: Ellen R. Gritz, Ph.D., Depart-ment of Behavioral Science, Unit 1330, The Uni-versity of Texas M. D. Anderson Cancer Center,P.O. Box 301439, Houston, TX 77230-1439; Fax:713-794-4730; E-mail: [email protected]

Received February 8, 2005; revision received July14, 2005; accepted July 28, 2005.

BACKGROUND. Successful cancer treatment can be significantly compromised by

continued tobacco use. Because motivation and interest in smoking cessation

increase after cancer diagnosis, a window of opportunity exists during which

healthcare providers can intervene and assist in the quitting process.

METHODS. The authors conducted a comprehensive literature review to discuss 1)

the benefits of smoking cessation in cancer patients, 2) current knowledge regard-

ing smoking cessation interventions targeted to cancer patients, and 3) treatment

models and state-of the-art guidelines for intervention with cancer patients who

smoke. The authors present clinical cases to illustrate the challenging nature of

smoking cessation treatment for cancer patients.

RESULTS. Continued smoking after cancer diagnosis has substantial adverse effects

on treatment effectiveness, overall survival, risk of second primary malignancies,

and quality of life. Although some encouraging results have been demonstrated

with smoking cessation interventions targeted to cancer patients, few empirical

studies of such interventions have been conducted. A range of intervention com-

ponents and state-of-the-art cessation guidelines are available that can be readily

applied to cancer patients. Case illustrations highlight the crucial role of healthcare

providers in promoting smoking cessation, the harmful impact of nicotine addic-

tion manifested in delayed and failed reconstructive procedures, and unique

problems encountered in treating patients who have particular difficulty quitting.

CONCLUSIONS. Despite the importance of stopping smoking for all cancer patients,

the diagnosis of cancer is underused as a teachable moment for smoking cessation.

More research is needed to empirically test cessation interventions for cancer

patients, and attention must be given to complex and unique issues when tailoring

cessation treatment to these individuals. Cancer 2006;106:17–27.

© 2005 American Cancer Society.

KEYWORDS: smoking cessation, cancer, survival, quality of life, nicotine depen-dence, relapse.

A lthough most smoking cessation efforts have been aimed at pri-mary prevention of cancer, the importance of stopping smoking

for individuals diagnosed with, being treated for, and surviving cancermust not be overlooked. A growing body of evidence indicates thatcontinued smoking after a diagnosis of cancer has substantial adverseeffects on treatment effectiveness, overall survival, risk of secondprimary malignancy, and quality of life.1–3 These adverse effects arefound both in patients with smoking-related cancers and in thosewith nonsmoking-related cancers. However, the diagnosis of cancer isunderused as a teachable moment to encourage smoking cessationamong patients, family members, and significant others. The medical,psychosocial, and general health benefits of smoking cessation forcancer patients provide a clear rationale for intervention. Moreover,

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© 2005 American Cancer SocietyDOI 10.1002/cncr.21598Published online 28 November 2005 in Wiley InterScience (www.interscience.wiley.com).

patient knowledge of these benefits may increase mo-tivation to stop smoking and help those who quit toremain abstinent. Two prominent behavioral inter-vention models based on providing personalized in-formation to increase motivation to quit—The Trans-theoretical Model (Stages of Change) and MotivationalInterviewing— have demonstrated the effectiveness ofsuch methods.4,5

Research indicates that after cancer diagnosis,motivation for and interest in smoking cessation aregreatly increased, particularly in patients with cancersstrongly related to smoking, such as head and neckand lung cancer.6 – 8 Thus, after a patient is diagnosedwith cancer, a window of opportunity opens duringwhich healthcare providers can intervene and assist inthe quitting process. This window of opportunity re-mains open throughout treatment and into the periodof cancer survivorship, because up to one-third toone-half of cancer patients either continue to smokeafter diagnosis or relapse after initial quit attempts,depending on tumor site and duration of follow-up.6,8 –13 In this article, we have provided an overviewof the benefits of smoking cessation in cancer patientsand the current state of knowledge concerning clinicalpractice guidelines and empirically supported smok-ing cessation interventions. We have included clinicalcase histories of cancer patients to illustrate chal-lenges to smoking cessation.

Importance of Smoking Cessation on Cancer TreatmentOutcomeImpact of smoking and smoking cessation on cancertreatment effectivenessFor the major cancer treatment modalities—radiationtherapy, chemotherapy, and surgery—smoking hasbeen found to diminish treatment effectiveness, exac-erbate side effects, and interfere with wound healing.Moreover, smoking is a risk factor for a wide range ofpulmonary, cardiovascular, infectious, and wound-re-lated complications.14

Lower rates of complete response to radiationtherapy have been reported for patients who continuesmoking compared with nonsmokers or smokers whoquit before treatment.15 Oral mucositis, loss of taste,xerostomia, weight loss, and fatigue are all exacer-bated by continued smoking.1 Because smoking in-creases the hepatic metabolism of many drugs, con-tinued smoking may decrease the therapeuticeffectiveness of chemotherapy and many other med-ications used to treat cancer patients.16

Smoking-related complications can be signifi-cantly reduced when patients stop smoking at least 4weeks before surgery, primarily postsurgical pulmo-nary complications.14,16,17 In addition, smoking cessa-

tion is strongly advised for patients undergoing surgi-cal treatment because continued smoking increasesthe risk of wound infection and has detrimental effectson wound healing.18 For example, current smokersundergoing transverse rectus abdominis myocutane-ous (TRAM) flap procedures for breast reconstructionhave an increased risk of flap necrosis, abdominal flapnecrosis, and hernia.19 It is recommended that breastreconstruction either be delayed or conducted withcaution in patients who smoke. Chang and colleaguesfound no differences in complication rates betweenformer smokers and nonsmokers when using theTRAM free flap procedure.19 In general, reconstructivesurgeons usually consider a case successful if a patientstops smoking 4 weeks before surgery, remains absti-nent postoperatively, and has healed wounds.20,21

Impact of smoking and smoking cessation on survivalratesThe detrimental effect of smoking on cancer survivalrates has been consistently demonstrated. Continuedsmoking after diagnosis has been found to negativelyaffect overall survival in patients with lung,22,23 headand neck,15 prostate,24 and cervical cancers.25 How-ever, stopping smoking before diagnosis and treat-ment can have a positive influence on survival rates.Studies have generally indicated that the longer theinterval between smoking cessation and initiation ofcancer treatment, the better the prognosis. Browmanand colleagues15 found that compared with head andneck cancer patients who continued to smoke afterdiagnosis, patients who quit smoking within 12 weeksbefore diagnosis had a mortality risk reduction of 40%,and those who quit smoking more than 1 year beforediagnosis had an even larger mortality risk reductionof 70%. Although a more recent study by these inves-tigators failed to detect an independent effect of con-tinued smoking on survival rates, it did support anadverse effect of smoking at diagnosis on both overalland cancer survival.26 Other findings among head andneck cancer patients indicate that after 2 years, thesurvival of patients who had quit smoking after diag-nosis approached that of patients who had neversmoked.27

Other studies have documented an adverse prog-nostic impact of smoking history on survival. In onestudy, head and neck cancer patients with any historyof smoking (former or current) were found to have notonly lower rates of survival but also lower rates ofdisease-specific survival and recurrence-free survivalcompared with patients who had never smoked.28 In astudy of patients with Stage I nonsmall-cell lung can-cer, Fujisawa and colleagues29 found a significantlyhigher overall survival rate at 10 years for patients

18 CANCER January 1, 2006 / Volume 106 / Number 1

reporting less than 30 pack-years of cigarette smoking(83.0%) than for patients with a history of more than30 pack-years (36.7%).

Impact of smoking and smoking cessation on risk ofsecond primary malignancyContinued smoking is known to increase the risk ofdeveloping a second primary malignancy at both theinitial tumor site and other sites. Although evidencesuggests a dose–response relation between cumula-tive tobacco use and development of second primarytumors, continued exposure to tobacco after diagnosisappears to be a more important risk factor.30 Multiplestudies have found that patients who continue smok-ing after diagnosis have an increased risk of develop-ing a second primary malignancy.31–34 Additional evi-dence suggests that individuals who successfully quitsmoking after lung cancer diagnosis can significantlydecrease their risk of second primary tumors com-pared with those who continue to smoke.33,35

Impact of smoking cessation on quality of lifeAnother important class of health outcomes thatshould be considered is quality of life (QOL). Whereasdisease and treatment-related variables can clearly in-fluence the QOL of cancer patients, cigarette smokingis another important variable to consider. Gritz andcolleagues prospectively investigated QOL outcomesin patients with head and neck cancer, who at baselineeither were current smokers or had quit within theprevious 12 months. Patients who were former smok-ers by 1-year follow-up reported higher QOL thanpatients who had not stopped smoking.36 Duffy andcolleagues9 also examined smoking behavior in headand neck cancer survivors and found that currentsmokers had significantly poorer physical functioning,general health perceptions, vitality, social functioning,and emotional functioning compared with nonsmok-ers.9 In a more recent study,11 continued smokingafter lung cancer diagnosis was associated with lowerQOL. In particular, persistent smokers demonstratedsignificantly poorer QOL outcomes compared withnever smokers, and intermediate levels of QOL werefound for former smokers as well as those who quitbetween diagnosis and subsequent evaluation. Al-though findings from these studies need to be repli-cated, the negative association between smoking andQOL is in agreement with associations observed ingeneral populations and other patient populations.These associations indicate that nonsmokers havehigher QOL than do current smokers, former smokershave higher QOL than do current smokers, and QOLdecreases as smoking intensity (number of cigarettesper day) increases.37– 41

Smoking Cessation Treatment for Cancer PatientsVery few smoking cessation interventions have beenempirically tested with cancer patients. Limited re-search suggests that many of the factors that influencecessation in cancer patients are similar to those seenin the general population (e.g., nicotine dependence,readiness to quit, age).6 Even though cessation inter-ventions should be tailored to the unique needs ofcancer patients (see below), treatment must be in-formed by evidence from smoking cessation studies inthe general population and other patient groups.

Clinical practice guidelineThe U.S. Department of Health and Human ServicesPublic Health Service has produced a clinical practiceguideline, based on a systematic review and analysisof scientific literature, containing a series of recom-mendations and strategies to assist healthcare provid-ers in delivering smoking cessation treatment.42 Thisguideline emphasizes the importance of systematicidentification of tobacco users by healthcare workersand of offering at least brief treatment to every patientwho uses tobacco. Specific strategies to guide clini-cians in providing brief interventions are offered andinclude: 1) identifying and documenting tobacco usefor every patient at every visit, 2) strongly urging everytobacco user to quit, 3) determining the willingness ofthe tobacco user to make a quit attempt, 4) usingcounseling and pharmacotherapy to aid patients inquitting, and 5) scheduling follow-up contact. Theseare referred to as the 5 As (Ask, Advise, Assess, Assist,and Arrange).42

The Clinical Practice Guideline summarizes effec-tive smoking cessation treatments and the benefits ofcombining treatment modalities.42 Techniques drawnfrom behaviorally based counseling models—includ-ing motivational enhancement,43 problems solving,and skills training—are empirically supported forsmoking cessation. Additional counseling compo-nents found to be highly effective include the provi-sion of social support and assistance in securing socialsupport outside of treatment. First-line pharmaco-therapies for smoking cessation include both nicotinereplacement therapy (i.e., nicotine patch, gum, in-haler, spray, and lozenge) and the sustained-releaseantidepressant bupropion (Zyban, GlaxoSmithKlineplc, London, UK), which have been shown to approx-imately double cessation rates.42

Tailoring of cessation treatment for cancer patientsUnique disease-related issues need to be taken intoaccount when implementing smoking cessation inter-ventions with cancer patients. Smoking-cessation

Smoking Cessation and Cancer/Gritz et al. 19

strategies may need to be modified because of physi-cal limitations imposed by disease and treatment. Forexample, it may be important to offer specially tai-lored suggestions regarding exercise regimens and di-etary change, which are often informal components ofsmoking cessation programs. Medical contraindica-tions to certain types of nicotine replacement therapymust also be recognized and appropriately managed.Thus, while pharmacological treatment is recom-mended for all patients as a component of smokingcessation intervention, individuals with oral cancersmay be unable to use oral forms of nicotine replace-ment such as the gum, spray, inhaler, or lozenge. Insuch cases, the nicotine patch or bupropion may bethe most appropriate alternative treatment. It is alsoimportant to be sensitive to stressors faced by patientsand associated psychological issues and mood disor-ders such as guilt, depression, and anxiety, all of whichmay impede smoking cessation efforts. Patients will beparticularly sensitive to any perceived blame for theirillness, especially when the disease is smoking-related.Instead, the healthcare provider should explain thestrong role of nicotine addiction and facilitate moti-vation for behavioral change using the social supportof family, friends, and healthcare professionals. In asample of lung cancer patients, Walker et. al. 13 pro-vided some noteworthy preliminary findings on howpatients’ “reactance”, or receptivity to advice and di-rection, may serve as a guide to offering directiveadvice and support. For example, patients who aremore adherent, in general, may benefit from moredirective advice and support, whereas more resistantand nonadherent patients may do better with lessdirective advice and support. This is certainly an areafor additional research.

As quit rates have been reported to be higher forpatients with cancers strongly related to smoking,6,7 itis likely that awareness of the connection betweendiagnosis and smoking status facilitates smoking ces-sation. Healthcare providers play a crucial role in un-derscoring this link. Education on the health risks ofcontinuing to smoke after diagnosis, regardless of can-cer type, and the health benefits of smoking cessationmay be particularly useful in increasing motivationand interest in quitting.

Helping patients to sustain smoking cessationposes another unique challenge in working with can-cer patients. Although relapses in healthy personsusually occur within the first week after cessation,relapses in cancer patients are often delayed becauseof surgical and other posttreatment healing. Gritz, etal. reported that among head and neck cancer patientswho relapsed to smoking after quitting successfully,the majority of relapses did not occur until 1– 6

months after surgery.44 This delay in relapse may sig-nal a waning motivation for abstinence as patientsrecover physically and return to their prediagnosislifestyle. Thus, interventions to prevent relapse andpromote sustained abstinence are particularly impor-tant as patients heal.

Empirically tested cessation interventions with cancerpatientsSeveral studies examining the efficacy of smoking ces-sation interventions designed specifically for cancerpatients were conducted within hospital settings anddelivered by nurses. The typical intervention used inthese studies consisted of three in-hospital visits, theprovision of educational materials, and five postdis-charge telephone calls. Findings indicated higher ab-stinence rates in the intervention group than in theusual-care control group; however, these rates variedgreatly from study to study. Across two studies, absti-nence rates at the time of the first postdischarge visitvaried between 65–75% for the intervention groupcompared with 43–50% for the control group.45,46

Wewers and colleagues47 reported abstinence rates of40% at 6-week follow-up for lung cancer patients us-ing this same intervention in a single group design. Inthe most recent study conducted with cancer patientsby these investigators, the abstinence rate in the in-tervention group was only 21%, compared with 14% inthe usual-care condition at 6 weeks postinterven-tion.48 However, a more modest treatment was usedwith only one in-hospital nurse visit, provision of ed-ucational materials, and five postdischarge telephonecalls. It was concluded that a more intensive interven-tion might be needed.

A randomized, controlled trial of a surgeon– den-tist-delivered intervention for patients with primarysquamous cell carcinoma of the upper aerodigestivetract was conducted by Gritz and colleagues.6,10,36 Inthis study, both intervention- and control-group pa-tients received personalized risk factor informationand strong advice to quit smoking from their surgeonor maxillofacial prosthodontist. Although the inter-vention group’s quit rates were not significantly in-creased by the addition of signed quitting contracts,tailored booklets, reminder postcards, and boostersessions at follow-up medical visits, the high quit ratesfor all participants (70.2% continuous abstinence at1-year follow-up) suggests that brief advice, given inthe context of medical care, is a powerful tool. Inanother study of physician-delivered advice, the po-tential need for more intensive treatment for somecancer patients was demonstrated by Schnoll and col-leagues.49 In this study, cancer patients with variousdiagnoses were randomly assigned to usual care with


unstructured smoking-cessation advice or a physi-cian-delivered smoking intervention based on Na-tional Institutes of Health guidelines. No differences incessation rates were found between the groups at the6- or 12-month follow-up, ranging from 12% to 14%.The higher quit rates found by Gritz and colleaguesare likely explained by the targeting of patients with asmoking-related cancer (i.e., head and neck cancer) bytheir direct treatment providers.

Additional studies have compared outcomes be-tween cancer patients and other participants in gen-eral smoking cessation programs conducted at theMayo Clinic Nicotine Dependence Center, which of-fered a range of treatments over time. A matched-pairdesign was used to retrospectively analyze abstinencerates at 6-month follow-up for patients with certaintypes of cancer compared with the general patientpopulation. Sanderson Cox and colleagues 50 reportedthat lung cancer patients were significantly more likelyto achieve 6-month tobacco abstinence than controls(other cancer patients and noncancer patients), 22%versus 14%. However, in another Mayo Clinic study,Garces et al.51 found no significant differences in ab-stinence rates between head and neck cancer patients(33%) and controls (26%). Both studies found thatduration of time between cancer diagnosis and smok-ing cessation treatment significantly affected tobaccouse outcome. Significantly higher abstinence rateswere found for both lung and head and neck cancerpatients treated within 3 months of diagnosis com-pared with those treated more than 3 months afterdiagnosis, emphasizing the importance of early treat-ment after diagnosis.

Case histories: the need for intensive smoking cessationinterventions for cancer patientsCancer patients who continue to smoke after physi-cian-delivered advice or other brief cessation inter-ventions are likely to require intensive interventionsthat combine multiple treatment modalities. The firstthree cases of the five presented below illustrate thedetrimental effects of continued smoking on cancertreatment outcomes and difficulties that cancer pa-tients face in quitting smoking and remaining absti-nent.

Case 1. This 52-year-old woman was diagnosedwith a Stage II infiltrating ductal carcinoma of herright breast. At the time of diagnosis, the patient wasdivorced with no known psychiatric history. She en-dorsed rare alcohol use and no drug use. She had ahistory of chronic obstructive pulmonary disease(COPD), intermittent bronchitis, and pneumonia. Shestarted smoking at age 16 years, and other than stop-

ping for about 4 years many years ago, she smokedbetween 1 and 2.5 packs per day until diagnosis. Be-tween diagnosis and treatment, her smoking de-creased to one cigarette per day, and she was noted tobe taking bupropion to assist with smoking cessation.

The patient underwent a right modified radicalmastectomy, followed by chemotherapy and radiationtherapy. Later, she developed recurrent upper respi-ratory infections and pneumonia. She indicated thatshe was smoking about a half pack of cigarettes perday. After repeated attempts at quitting with subse-quent relapse, the patient enrolled in a smoking ces-sation clinic. She was treated with behavioral counsel-ing, nicotine patches, and bupropion. She reportedlyremained abstinent for 5 months, and then she un-derwent a delayed right breast reconstruction with aTRAM pedicle flap. Her postoperative course wascomplicated by fat necrosis in the right breast and insome of the skin at the TRAM donor site. The patientadmitted that she resumed smoking (1–2 cigarettesper day) upon discharge from the hospital. The patientwas repeatedly advised by her surgeon that continuedsmoking would have a deleterious effect on her heal-ing and prolong her recovery. The patient continuedto intermittently endorse and deny occasional smok-ing.

She then underwent debridement of the tissue atthe abdominal donor site and the part of the TRAMflap comprising the upper half of her right breast.Later, the abdominal donor site was closed with a skingraft. The patient was informed that complete smok-ing cessation was required before any surgery could beperformed to complete the reconstruction of her rightbreast and revise the donor site scar. She was referredto a smoking cessation clinic where she receivedcounseling and bupropion treatment. Approximately10 months after the skin graft procedure, she statedthat she had remained abstinent from smoking forseveral weeks. To verify her compliance with smokingcessation, a urine specimen was obtained; the urinecotinine was negative for nicotine use.

She underwent a revision of her right breast witha latissimus dorsi myocutaneous flap and revision ofthe TRAM donor site. A left prophylactic mastectomywas performed at the same time as this procedure. Aurine cotinine level was obtained during the surgicalprocedure and was positive for nicotine use postop-eratively. The patient continued to deny smoking. Shesuffered wound healing problems involving skin edgenecrosis on the back, which eventually resolved. Thepatient underwent the next stage of reconstructivesurgery about 4 months later. She tolerated this sur-gery well and had no smoking-related complications.


Case 2. This 44-year-old married woman was diag-nosed with a large squamous cell carcinoma of the leftcheek. The patient admitted to smoking approxi-mately a half pack of cigarettes a day for the last 21years. She denied alcohol or illicit drug use. The tumorwas widely excised, and the resulting large cheek de-fect was closed with a large local skin flap. At dis-charge, the flap was noted to be viable; however by the10th postoperative day, the distal one-third of the flaphad become necrotic. Although the patient had re-ported discontinuing tobacco use before surgery, sheresumed smoking soon after discharge.

The necrotic cheek skin was surgically debrided,and the wound closed with a full-thickness skin graft.The skin graft survived transplantation, but the thin-ness of the graft resulted in a significant contour de-formity. Unfortunately, the patient became signifi-cantly depressed because of facial disfigurement, anoutcome that she ascribed to the reconstructive sur-geon. The patient further reported increasing maritaldiscord about her physical appearance and the lack offamily support for smoking cessation. She requested asecond opinion to remove the skin graft and correctthe deformity. Another plastic surgeon evaluated thepatient and felt that that surgical correction was pos-sible if the patient could quit smoking and her depres-sion was adequately treated. The patient was referredto the psychiatry service and smoking cessation clinic,and additional surgery to correct the deformity waspostponed until she could abstain from smoking for atleast 1 month before the surgical intervention.

In smoking cessation clinic, the patient reportedcontinuing to smoke approximately 3– 4 cigarettes perday. She was initially prescribed bupropion and a 7 mgstarting dose of nicotine replacement patches. Shewas educated about components of nicotine addic-tion, learned problem-solving techniques, and wasscheduled for additional counseling sessions. The pa-tient subsequently elected to start a 21 mg dose ofnicotine replacement that had been previously madeavailable to her. This led to alterations in her treat-ment course, as extended time was needed to gradu-ally reduce the nicotine levels in the patches. Sheattended only one follow-up session in the smokingcessation clinic.

Two months later, the patient stated that she hadabstained from smoking and using nicotine patchesfor 3 continuous weeks. Several weeks later, she un-derwent subcutaneous placement of tissue expanderson the left side of her face, neck, and upper chest wallregion. However, the patient’s preoperative cotininelevel was later found to be positive for nicotine, indi-cating she had either continued to smoke or was usingnicotine replacement treatment before surgery. Dur-

ing the next clinic visit, the test results were presentedto the patient, but she continued to deny smoking andrefused to provide a urine specimen for a cotininelevel to verify compliance with smoking cessation. Thefollowing week, she willingly provided a urine sample;however, she became tearful and confessed that shehad been smoking about four cigarettes a day whenasked to also provide a saliva sample for a cotininelevel during the same visit. The patient obtained apsychiatric evaluation. She endorsed symptoms ofchronic low mood for the past 2–3 years, low self-esteem, and significant feelings of guilt about continu-ing to smoke. She was diagnosed with dysthymia withanxious features, prescribed antidepressant medica-tion, and subsequently engaged in individual therapysessions.

Ultimately, infection led to exposure of the tissueexpanders, and they had to be removed. The neck skinwas advanced without tension to remove some of theskin graft. Postoperatively, the patient continued tosmoke cigarettes despite the surgeon’s warnings ofcontinued difficulty with wound healing. The lastknown clinical contact that addressed the patient’ssmoking status indicated that she had not yet ab-stained from smoking. Moreover, her spouse was notsupportive of her efforts at smoking cessation andcontinued to smoke in front of her.

Discussion of cases. In the two cases presented above,the harmful impact of nicotine addiction was man-ifested in delayed and failed reconstructive proce-dures at psychologically sensitive and value-ladenbody sites—the breast and the face. Although surgi-cal complications related to skin and fat necrosiscannot be entirely eliminated with smoking cessa-tion, continued smoking undoubtedly increases therisks of such adverse effects.18,52 Both patients hadlong histories of moderate to heavy smoking andalleged periods of intermittent smoking reductionor abstinence. Treatment for nicotine dependencein these patients was complicated by repeated re-lapses to smoking (Case 1), depressive symptomsand seemingly inadequate social support (Case 2).In both cases, physicians took an active role inpromoting smoking cessation, advised on the risksof continued smoking, and delayed nonessentialsurgical procedures until smoking cessation couldbe achieved. Unfortunately, in Case 2, the patientwas unable to be truthful about her continuedsmoking. The surgeon requested biologic samplesfor confirmation of abstinence on repeated visits toprovide the optimal medical care. This led to apsychiatric referral and appropriate evaluation andtreatment for the patient’s mood disorder.


In cases such as these, simultaneous, multipleapproaches may be necessary. Consultation withsmoking cessation specialists is vital for these patients.Treatment strategies should be guided by a thoroughassessment of tobacco use, which includes examiningcurrent level of motivation to quit and remain absti-nent. It is recommended that smoking behaviors con-tinue to be evaluated (and biochemically verified) bythe treating physician at each follow-up visit. For pa-tients such as the woman described in Case 1, partic-ular emphasis should be given to providing an inter-vention that focuses on relapse prevention. Inaddition to counseling and behavioral strategies topromote relapse prevention, it is recommended thatsmoking behaviors continue to be evaluated by thetreating physician at each follow-up visit. This willallow patients to discuss any difficulties with quitting(e.g., craving, withdrawal symptoms, depression,medication side effects, and high-risk situations forrelapse) and facilitate prompt encouragement andsupport for resuming cessation in the event of a re-lapse to smoking.

In both cases described above, higher doses ofnicotine replacement therapy over longer treatmentperiods, concomitant with pharmacologic treatmentof depression, should be considered. For patients suchas the woman described in Case 2, thorough assess-ment and treatment of depression and other mooddisorders is likely to be critical to successful treatment.Moreover, Case 2 highlights the importance of attend-ing to and understanding the patient’s existing socialnetwork. Behavioral strategies to improve social skillsand facilitate effective communication with spouses,family members, or other significant figures in thepatient’s life are recommended. Systemic interven-tions to actively involve family members should alsobe considered. In this way, the patient can be made afull partner in the therapeutic alliance against nicotineaddiction, not its failed victim.

Case 3. This 64-year-old man was diagnosed with alarge squamous cell carcinoma of the larynx. Beforediagnosis, the patient had smoked 3 packs per day for40 years. The patient is married and has no knownpsychiatric history or history of illicit substance oralcohol abuse. The patient reported that he reducedhis cigarette consumption to a half pack per day afterdiagnosis. He was initially treated with chemotherapyand radiation. At the advice of his healthcare provider,the patient engaged in smoking cessation treatment,which consisted of behavioral and pharmacologic in-terventions. He subsequently relapsed to smoking anddid not return for additional counseling sessions.

Within 1 year, the patient was diagnosed with an

adenocarcinoma of the lower right lobe of the lung.Surgery was delayed until the patient could abstainfrom smoking to minimize his chances of periopera-tive pneumonia. Approximately 1 month later, thepatient underwent a right lower lobectomy with me-diastinal lymph node dissection to remove the tumor.He resumed smoking after surgery, and approximately3 months later was noted to have chronic nicotine andreflux changes to his larynx. The patient had intermit-tent contact with a smoking cessation counselor, buthe was noted to continue smoking approximately ahalf pack per day.

One year later the patient reported persistentcough, frontal headaches, and chronic postthoracot-omy pain. He subsequently enrolled in a SouthwestOncology Group (S0002) smoking cessation trial dur-ing which he received: behavioral advice delivered byhealthcare providers; pharmacotherapy including theuse of nicotine replacement patches and randomiza-tion to bupropion or placebo; targeted written mate-rials (Public Health Service-based tip sheets, etc.); and5 follow-up telephone calls to reinforce the interven-tion over a 10-week interval. This patient was notrandomized to the arm of treatment that includedbupropion (i.e., he received placebo.). With this inter-vention, the patient effectively established a quit dateand abstained from smoking for 3 weeks. After theonset of general feelings of ill health and the develop-ment of an upper respiratory tract infection, the pa-tient stopped adhering to smoking cessation treat-ment and relapsed to smoking. He was unable to setanother quit date and eventually declined to continueparticipating in the intervention. The patient contin-ued to smoke approximately a half pack of cigarettesper day. His chest film and computed tomography(CT) scan showed changes consistent with emphy-sema. During the following year, repeat CT andpositron emission tomography (PET) scans showedprominent, but stable, paratracheal lymph nodes. Thepatient is scheduled for annual follow-up evaluationsto monitor the status of these nodes. He continued tosmoke approximately 1 pack per day as of the lastclinical contact.

Discussion of case. For patients such as the man de-scribed in Case 3—a seriously ill patient with a long-term history of heavy smoking and only limited peri-ods of smoking reduction and abstinence—thepresence of multiple primary cancers, comorbid dis-ease, and deteriorating health may all contribute todeclining motivation to maintain abstinence and seekfurther smoking cessation treatment. In such cases,the complications and symptoms of advanced diseasemay be mitigated by eliminating smoking. The 10-


week intervention in which this patient participatedwas not sufficient to promote long-term smoking ces-sation. Although the optimal length of interventionmay vary, prolonged pharmacologic treatment withboth nicotine replacement and an antidepressant aswell as sustained guidance from healthcare providersregarding problem-solving and skills training are indi-cated. Psychological issues including guilt, depression,anxiety, and stress should also be considered andmanaged appropriately. Intensive psychological sup-port, including a family conference, may be helpful,because such patients may also benefit from involve-ment of spouses and other important members oftheir social network in their treatment. It is particu-larly important to assess whether these patients livewith individuals who smoke, as this can represent asignificant barrier to smoking cessation (as in Case 2).

Examples of successful smoking cessation treatmentIn the final two clinical cases, the healthcare provid-er’s active role in promoting smoking cessation led topositive outcomes.

Case 4. This 54-year-old woman was diagnosed withductal carcinoma in situ in both breasts. She is mar-ried, with no alcohol or drug use and no known psy-chiatric history. She had a history of smoking at leasta half pack per day, but she had quit for the past 7years. One month before her diagnosis, the patientresumed smoking 5– 6 cigarettes daily. Subsequently,she underwent wide excision of the left breast tumorand segmental mastectomy of the right breast. Al-though the margins of resection were negative fortumor in the left breast, residual disease was found atthe deep margin of the right breast.

Because she had carcinoma in situ in both breastsand a significant family history of breast cancer, shewas advised to undergo a modified radical mastec-tomy and immediate reconstruction of both breasts.During the consultation with the plastic surgeon, sheadmitted to continued smoking. The patient was con-sidered to be an appropriate candidate for a TRAMfree flap breast reconstruction provided she stoppedsmoking as soon as possible and remained abstinentbefore and after surgery. The plastic surgeon fullydiscussed the increased risks for necrosis of the breastskin, the skin and fat of the TRAM flap, and its donorsite because of inadequate perfusion of blood throughthese tissues if she continued to smoke. The patientreportedly took the advice of the surgeon and stoppedsmoking.

Approximately 3 weeks later, she underwent askin-sparing mastectomy and immediate reconstruc-tion of both breasts with a TRAM free flap. Six months

after surgery, the patient was evaluated for the nextstage of breast reconstruction, involving a revision ofthe reconstructed breasts and bilateral nipple recon-struction. From the initial consulting visit with theplastic surgeon through all stages of breast reconstruc-tion, the patient remained abstinent from smokingand did not suffer a major complication.

Case 5. This 63-year-old woman presented with asquamous cell carcinoma of the floor-of-mouth andwas evaluated for possible reconstruction after tumorresection. She is married, does not drink alcohol, andhas no history of psychiatric disorder. The patient hadsmoked 1.5 packs of cigarettes a day for 40 years andhad never attempted to quit. She was seen by a smok-ing cessation specialist and started on buspirone, anantianxiety agent that has been used with some suc-cess in smoking cessation treatment. The patient wasinformed that she must stop smoking, preferably theday of the consultation. She was seen again 1 and 2weeks later; she had markedly decreased her smokingto 2 cigarettes a day, but she did not totally quit untilher surgery.

The patient underwent composite tumor resec-tion and immediate reconstruction of the missingmandible, floor-of-mouth, and part of the oral tonguewith a fibula osteocutaneous free flap. The patient’shospital course was without problems. On the 6th

postoperative week, she began radiation therapy andexperienced no significant complications during re-covery. The smoking cessation specialist contactedher family by telephone 3 months after surgery andlearned that she was not requesting nor discussingsmoking again. She has been able to abstain fromtobacco and nicotine use for 5.5 years.

The patient developed lung cancer 3.5 years afterher head and neck diagnosis. She was treated by re-section of the upper lobe of the right lung, along withthree ribs and the transverse processes of the 3rd and4th vertebrae. However, she recuperated successfullyfrom this treatment and is alive and free of disease.

Discussion of casesThe two successful smoking cessation cases illustrateseveral salient points. Patients who are lighter smok-ers, have a long history of past successful quitting, anda relatively short relapse period (Case 4) are excellentcandidates for resuming abstinence. Their self-esteemregarding quitting is likely high, and they can drawupon past experience to deal with temptation, countupon family support, as well as benefit from the strongand targeted advice of the treating physician. In theexample of a heavy smoker with no history of cessa-tion (Case 5), the astute evaluation by a smoking ces-


sation specialist with the prescription of appropriatepharmacotherapy and follow-up sufficed to support asuccessful quit effort. Interestingly, although this pa-tient developed a second primary tumor, she was cur-atively treated for it, maintained abstinence from cig-arettes, and has not suffered further disease. It is verypossible that her successful abstinence has contrib-uted to her long-term recovery.

Summary and RecommendationsThe importance of smoking cessation for all cancerpatients, regardless of whether the primary tumor issmoking-related, has been clearly demonstrated. It isstrongly urged that patients who continue to smokeafter diagnosis be identified and that smoking cessa-tion interventions tailored to these patients be mademore readily available. Patients and caregivers wouldbenefit from learning about the adverse effects of con-tinued smoking on cancer treatment effectiveness,wound healing, treatment side effects, survival rates,risk of secondary malignancies, and overall QOL.

A range of intervention components, drawn fromextensive research on smoking cessation in the gen-eral population and in other patient groups, is readilyapplicable to cancer patients. Although more researchis clearly needed to empirically test smoking cessationinterventions with cancer patients, encouragingresults have been demonstrated with brief physician-delivered advice and nurse-delivered hospital cessa-tion programs. More intensive interventions, com-bining elements of behavioral therapy andpharmacotherapy, have been developed for cancerpatients but have not yet been extensively tested.

Practicing oncologists would benefit from obtain-ing knowledge of the appropriateness of interventionsand the importance of prioritizing cessation alongwith other treatment adjuvants. At the initial consul-tation session, it is strongly recommended that physi-cians inquire about and document a patient’s smokinghistory, current smoking status, and willingness tomake a quit attempt (if applicable). The primary ele-ments of smoking history to obtain include currentsmoking status, number of cigarettes smoked daily,age at which smoking began, number of years smoked,cessation history, other forms of tobacco use, degreeof addiction, and readiness to quit. In addition, smok-ing behaviors should be routinely evaluated and doc-umented at each follow-up visit. For patients whohave a recent smoking history, consideration shouldbe given to the use of biochemical verification ofsmoking status (e.g., expired carbon monoxide levelsor urine, saliva, or serum cotinine levels). This practicenot only would allow physicians to have more accu-rate data with which to guide complicated treatment

decisions (e.g., those related to surgery and radiationtherapy) but also may facilitate a more candid discus-sion of motivational factors and individual barriers toquitting.

We offer several recommendations for future re-search regarding smoking cessation treatment for can-cer patients. With one exception,49 intervention stud-ies for cancer patients have focused solely onindividuals with smoking-related cancers. Futurestudies need to include patients with nonsmoking-related cancers. Future studies should also investigatethe benefits of targeting interventions on the basis ofcancer site because of potential differences betweensmoking-related and nonsmoking-related tumors. Re-search is ongoing to identify specific genes associatedwith nicotine dependence, response to treatment, andcancer susceptibility.53–56 For example, the identifica-tion of a lung cancer susceptibility gene may allowintensive early intervention and tailoring of risk mes-sages to healthy individuals being screened for lungcancer and to lung cancer patients at risk for secondprimary tumors. In addition, the identification ofgenes associated with nicotine dependence and/ortreatment response may allow tailoring of pharmaco-logic treatment, both type and dose, to cancer patientson the basis of genotype. Needless to say, even in theabsence of genetic information, all patients whosmoke, who are at elevated risk, or who are alreadydiagnosed with cancer should be offered smoking ces-sation treatment.

Further studies should be conducted to determineindividual barriers to smoking cessation among can-cer patients. Risk perceptions and cognitive beliefsabout smoking have been extensively studied in thegeneral population but are not fully understood incancer patients. Previous studies have generally indi-cated that smokers tend to minimize the personalhealth risks of smoking or have incomplete knowl-edge, particularly of potential disability.57–59 Severalself-exempting beliefs have been identified in adultsmokers that are used to rationalize smoking behaviorand that predict intention to quit smoking.60 Impor-tant differences in smoking cognitions may exist be-tween smokers in the general population and thosediagnosed with cancer, and between smokers diag-nosed with smoking-related cancers and those diag-nosed with nonsmoking-related cancers. A recent sur-vey of survivors of nonsmoking-related cancers(breast and prostate) and colorectal cancer, which isweakly related to smoking, reported a high level ofinaccurate belief (75– 81% of respondents) that to-bacco was an important cause of all three cancers,plus a relative overemphasis on stress (44 – 68%) andenvironmental pollution (58 –78%). Other behavioral


and lifestyle factors, including drinking alcohol, diet,obesity, and physical inactivity were generally en-dorsed at lower rates. 61 Such identification of smok-ing-related beliefs among cancer patients, as well asdispositional variables that affect treatment adher-ence,13 could be used to further tailor smoking cessa-tion interventions for this population.

Smoking cessation interventions for cancer pa-tients can be further improved by using standardizedassessment tools and sound methodology drawn fromsmoking cessation literature on healthy populations. Itis important to recognize the range of outcomes forthese patients as they relate to disease and functionalstatus as well as to overall QOL. The inclusion ofadequate follow-up periods (at least 1 yr) is also nec-essary to assess the duration of effects and to providedata comparable to those available from healthy-pop-ulation studies.

Cancer patients who are able to stop smoking andremain abstinent after diagnosis and treatment arelikely to reap substantial physical and psychologicalbenefits, including improved QOL and prolonged sur-vival. Additional benefits may extend to family mem-bers who choose to act on this teachable moment toimprove their own health and provide vital psycholog-ical and social support through their actions.

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Successes and failures of the teachable moment

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