Helping cancer patients quit smoking is the down-to-earth goal for a lofty program, the National Cancer Institute’s Cancer Moonshot program.

UCHealth University of Colorado Cancer Center – Anschutz Medical Campus will be part of the expansive initiative to drive down smoking rates among cancer patients.

The Cancer Center is one of 22 NCI-designated institutions that will share $10 million in grant funds over two years from the Cancer Center Cessation Initiative. The aim: develop sustainable smoking cessation programs that help all cancer patients quit smoking.

The NCI has long targeted tobacco use as a direct cause of cancer and an impediment to treating patients with a cancer diagnosis, said Arnold Levinson, PhD, project leader for the Cancer Center and an associate professor with the Colorado School of Public Health. Research funded by the NCI as far back as the 1970s led to a simple conclusion: medical centers that treat cancer patients should also treat tobacco use, Levinson said. Some NCI-designated centers, notably Memorial Sloan Kettering Cancer Center in New York, took that message to heart and developed robust tobacco treatment programs, but commitment among cancer centers overall to a voluntary effort was uneven, Levinson said.

NCI has taken a different tack with the Cancer Center Cessation initiative. It replaces reliance on volunteer efforts with seed funds for programs that commit to meeting specific goals. These include identifying every cancer patient who uses tobacco; connecting him or her with specialists who are trained in counseling techniques that increase the likelihood of a quit attempt; providing appropriate cessation medication and counseling, and supporting tobacco users throughout the process of quitting. Each program also must show that it will keep its tobacco treatment program going for at least another three years after the grant funding runs out.

“The NCI is now saying, ‘Don’t study it, do it,’” Levinson said.

The Cancer Center has only begun work toward developing its program, but its basic goal is clear, Levinson said. “At the core of it all, we want to find a way to link all our cancer patients who smoke with treatment for cessation.”

Clearing the way

That will require devoting a large portion of the grant funding to developing changes to the Epic electronic health record (EHR), Levinson said. These are necessary to support a new workflow that ensures that every patient seen in a Cancer Center clinic is assessed for smoking status and that those who are current smokers are contacted by a tobacco treatment specialist (TTS) at UCHealth University of Colorado Hospital. These specialists can help smokers assess their own motivation to quit and arrange appropriate counseling and medications for quitting.

Levinson said the program hopes to have initial work on the EHR completed in April. Plans are also in place to bring in additional TTS staff to handle referrals from UCHealth cancer clinics, he said.

The strategy will allow physicians to focus on cancer care while their patients receive specialized assistance to quit smoking, said Allen Wentworth, RRT, MEd, director of Respiratory Services for UCHealth University of Colorado Hospital. “The program will put the right people to the right job,” Wentworth said.

He noted that TTSs rely on “motivational interviewing” in approaching patients who smoke. The idea is to explore with patients their reasons for smoking and possible reasons for quitting. “That is a key to stopping the wall from going up when patients are asked about their smoking,” Wentworth said.

Extending success

With the new initiative, the Cancer Center hopes to build on smoking-cessation successes already achieved at University of Colorado Hospital, which launched an inpatient program – the Colorado Model of Inpatient Tobacco Treatment (COMITT) – in 2011. The program uses the EHR to identify smokers and send referrals to TTSs who make an initial bedside contact to introduce themselves and explore with patients their openness to considering a quit attempt and their own reasons for trying.

Those who agree to it receive nicotine replacement therapy (NRT) medications and regular counseling to help them stay on track after they leave the hospital. Wentworth said the data available shows COMITT maintains three- and six-month quit rates of 28 percent to 30 percent among inpatients contacted by the hospital’s three TTSs.

That’s considered a very good success rate, but because cancer patients receive most of their care in clinics and infusion centers, rather than in the hospital, COMITT reaches relatively few of them, Levinson said. In addition, COMITT supplies only NRT, while the new program will offer patients other medications, such as Chantix, after oncology pharmacists review them to ensure they have no potentially harmful interactions with drugs that treat their cancer, Levinson added.

Mixed messages

It might seem self-evident that a cancer diagnosis would give an individual a strong incentive to quit. Yet one survey concluded that nearly two-thirds of cancer survivors who smoked before their diagnosis continued to smoke afterwards. There are deep-seated reasons for that apparently baffling fact, said Kathleen Moreira, a TTS at University of Colorado Hospital. Moreira, who sees patients in both the inpatient and outpatient settings, spent two days at Memorial Sloan Kettering in early December, gleaning information about setting up an evidence-based smoking cessation program that is an integral part of a patient’s cancer care.

“There is often an assumption by family members and providers that patients need to stop smoking just because they have cancer,” Moreira said. But patients might resist for a variety of reasons, she added. Some may not want to add the stress of quitting to the ordeal of cancer treatment. Others may have a poor cancer prognosis and conclude there is no point in giving up cigarettes. Many may not be clear about how smoking can impede their response to treatment, slow their healing, and increase the risk of their cancer recurring. That’s not to mention the difficulty of talking about sticking with a habit that society increasingly marginalizes while figuratively wagging a scolding finger at those who persist.

“There is often a deep sense of guilt, shame and regret among smokers,” Moreira said. “Compassion is what is needed, and a TTS may be a patient’s only cheerleader.” For example, a cancer patient who cuts down from 10 to five cigarettes a day might be chastised by some for not quitting completely, while the TTS celebrates the improvement.

“That’s an accomplishment,” Moreira said. “It’s our job to offer support, with no judgment.”

Moreira said she and the other participants at the Memorial Sloan Kettering conference also received extensive education about pharmacotherapy. That information helped her gain an understanding of the interactions between smoking cessation medications and treatments for different types of cancer. She believes that knowledge offers another avenue to a neutral discussion with patients about the effects of smoking.

“It can take the conversation to a place of education,” Moreira said.

Multiple incentives: helping cancer patients quit smoking

It’s vitally important to patients, providers and all of UCHealth that the new program succeed, Wentworth said.

“We’ve always said that for active smokers, the most important thing is to quit,” he said. “It’s more important than diet, more important than exercise. For cancer patients, quitting will help with treatment and their response to it. If we can help people to quit, they will be more likely to succeed with their first round of intervention. We hope also to show the financial advantage of doing that – because the first round of intervention is significantly less expense than additional rounds.”

Moreira said she looks forward to the day when tobacco treatment for cancer patients who smoke is routine.

“One of the most important perspectives for me as we implement this program is to see tobacco treatment for cancer patients as just like any other part of their treatment,” Moreira said. “If they had a heart condition and had cancer they would have a cardiology consult – without question. If they had diabetes with cancer they would have diabetes education, follow-up and management, along with their cancer care.”

Unfortunately, patients who smoke may blame themselves for causing their cancer, Moreira said, and society may view them unsympathetically for the same reason. But in her view, the debate is easily settled.

“The outcomes for patients when they can quit smoking are so much better,” Moreira said. “It should just be an accepted part of cancer care. Patients deserve to have counseling, medication and follow-up – just as you would for any other condition.”