JHOP - September 2015 Vol 5, No 3 - Editorial
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Sandra Cuellar, PharmD, BCOP
PharmD, BCOP

The facts and statistics on harmful and fatal effects associated with the use of tobacco products have been well-documented in the medical and economic communities.

The US Department of Health & Human Services estimates that the annual economic burden of tobacco use is nearly $170 billion in direct medical costs, and $156 billion in lost productivity.1,2 Despite its known carcinogenic potential, cigarette smoking remains the leading cause of preventable death in the United States. According to the American Cancer Society, tobacco use is associated with >30% of all cancer deaths and 87% of all lung cancer deaths.2 Tobacco use in patients with cancer is associated with several negative outcomes, including increased treatment-related toxicity, increased risk of secondary cancers, decreased quality of life, and decreased survival.

Several legislative changes and other marketing efforts have focused on smoking cessation and the prevention of tobacco-associated outcomes. However, efforts in campaigning against continued smoking in patients already diagnosed with cancer have not been as vigorous in comparison. Up to 58% of patients continue to smoke after being diagnosed with cancer, despite the significant consequences.3,4

Cessation Support for Patients with Cancer

Notwithstanding the obvious beneficial effects of smoking cessation in patients with cancer, medical oncologists provide limited smoking cessation programs as part of their standard of care. In a 2012 study, an online survey sent to 18,502 American Society of Clinical Oncology (ASCO) members, investigators asked about practice patterns regarding tobacco assessment, cessation support, perceptions of tobacco use, and barriers to providing cessation support for patients with cancer.5 Unfortunately, only 1197 members responded; however, the data collected provided insight on oncology providers and their perception of smoking cessation in contemporary times. The survey results demonstrated that oncology providers routinely ask their patients about tobacco use, and, if warranted, to quit. In addition, the majority of oncologists advise their patients to stop using tobacco. Only 44% of medical oncologists routinely discussed medication options with patients, and only 39% provided cessation support. The survey also included questions regarding barriers to offering smoking cessation programs. Interestingly, one of the dominant reasons for oncologists not offering enhanced smoking cessation services was because of inadequate training.

Since the publication of this study by Warren and colleagues,5 the oncology community has strengthened its efforts to encourage providers to assist their patients with tobacco cessation. In 2013, ASCO updated their Tobacco Cessation Policy Statement to include recommendations for healthcare providers to enhance provider education, support coverage of all US Food and Drug Administration–approved tobacco cessation services, increase global tobacco control, and support legislative and regulatory efforts to curb tobacco use.3 In addition, ASCO also recommends that tobacco use be discussed by the medical oncologist at the initial presentation of the patient, as well as throughout treatment. Furthermore, ASCO promotes the offering of tobacco cessation–focused education at ASCO meetings and in its publications.

ASCO is not the only organization dedicated to encouraging tobacco cessation in patients with cancer. The National Comprehensive Cancer Network (NCCN) has also focused their attention on this cause. In March 2015, the NCCN added smoking cessation guidelines to their library of supportive care guidelines.6 These guidelines, which focus on smoking cessation recommendations for patients with cancer, include general principles of smoking cessation, evaluation and assessment, general approaches to smoking cessation during cancer treatment, smoking-associated risks for patients with cancer, resources for patients and providers, principles of smoking cessation pharmacotherapy, and principles of behavior therapy. The addition of these guidelines offers healthcare providers in the oncology community access to current recommendations on smoking cessation.

Unique Opportunities for Pharmacists

Oncology and community pharmacists are in a unique position to assist in the improvement of smoking cessation programs for patients with cancer. It has been welldocumented in the literature that pharmacist interventions for smoking cessation are feasible and effective in community and outpatient settings.7 Pharmacists are recognized for their health promotion, and have regular face-to-face interactions with patients. In addition, patients identify pharmacists as healthcare team members who are knowledgeable about smoking cessation. Several institutions in the United States have clinical oncology pharmacists educating patients about their cancer therapy, and conducting medication reconciliation.

The addition of a smoking cessation component to their responsibilities may be another method to maximize oncology practices, and improve patient outcomes. Studies have shown that patients who attempt to quit tobacco using a tobacco intervention program are significantly more likely to quit than those patients who try to quit on their own.8 According to the US Department of Health & Human Services, quit rates for patients who use counseling alone, medication alone, or a combination of counseling and pharmacologic intervention are 15%, 22%, and 22% to 28%, respectively. Therefore, a combination of pharmacologic intervention, as well as behavior therapy (counseling), is essential for smoking cessation programs to be successful. In addition, oncology pharmacists are positioned to make important recommendations on the type of, and route of administration for, smoking cessation products in patients with cancer. For example, patients who develop or may develop stomatitis are not likely candidates for nicotine lozenges or gum.

In addition to appropriate selection of nicotine replacement therapies, pharmacists can provide access to nicotine replacement products, review for potential drug interactions, and adjust doses as clinically indicated. The other major advantage of pharmacists assisting oncology practices with smoking cessation is that most smoking cessation products are available over-thecounter. In addition, several health plans and government insurance plans provide coverage for prescription and nonprescription tobacco cessation products. Pharmacists, in general, are knowledgeable and well-informed on the insurance coverage and access of these medications for patients.

Advocacy and Smoking Cessation Programs

Advocating smoking cessation is important in cancer prevention, as well as in patients with cancer. Another subset of patients in oncology who can benefit from smoking cessation programs are cancer survivors.

In 2012, the Commission on Cancer updated its standards for accreditation to include development and dissemination of survivorship care plans to be phased in for 2015.9 In complying with the mandatory standards, cancer centers will need to implement programs to improve outcomes for patients. In an article by Wolin and colleagues, the authors described the implementation of smoking cessation programs in oncology practices for the purpose of expanding cancer survivorship programs.10 They outlined the 6 major components that a smoking cessation program for cancer survivors needs for it to be successful. It includes goals, program options, metrics, implementation, and evaluation. Pharmacists are qualified and capable of executing all of the aforementioned components. In addition, reimbursement opportunities exist for pharmacists. Medicare has billing codes the pharmacist can utilize to bill for smoking cessation services.11 The biggest hurdle pharmacists may face is the additional workload.

Recognition of the potentially fatal consequences of smoking is well-known and documented. As oncology medical organizations rally to increase awareness and promote the provision of better services to cancer patients, pharmacists have the opportunity to serve a vital role in this movement. Oncology pharmacists cannot only provide smoking cessation services and assist in the development of smoking cessation programs; they can also conduct research and publish on this topic. In addition, a pharmacist-driven smoking cessation program can provide an avenue for pharmacists to play an active role in cancer survivorship.

References

  1. US Department of Health & Human Services. The health consequences of smoking— 50 years of progress. A report of the surgeon general. www.surgeongeneral. gov/library/reports/50-years-of-progress/full-report.pdf. Published 2014. Accessed August 4, 2015.
  2. American Cancer Society. Cancer facts & figures 2013. www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036845.pdf. Published 2013. Accessed August 4, 2015.
  3. Hanna N, Mulshine J, Wollins DS, et al. Tobacco cessation and control a decade later: American Society of Clinical Oncology policy statement update. J Clin Oncol. 2013;31:3147-3157.
  4. Cox LS, Africano NL, Tercyak K, Taylor KL. Nicotene dependence treatment for patients with cancer. Cancer. 2003;98:632-644.
  5. Warren GW, Marshall JR, Cummings KM, et al. Addressing tobacco use in patients with cancer: a survey of American Society of Clinical Oncology members. J Oncol Pract. 2013;9:258-262.
  6. National Comprehensive Cancer Network. Smoking cessation. Version 1.2015. http://cancer.osu.edu/~/media/Files/Shared/Press-Releases/Cancer/2015/NCCN-smoking-cessation-guideline.pdf?la=en. Published March 9, 2015. Accessed August 4, 2015.
  7. George J, Thomas D. Tackling tobacco smoking: opportunities for pharmacists. Int J Pharm Pract. 2014;22:103-104.
  8. US Department of Health & Human Services. Treating tobacco use and dependence: 2008 update. www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/tobacco/clinicians/update/treating_tobacco_use08.pdf. Published
    May 2008. Accessed August 4, 2015.
  9. American College of Surgeons. Cancer program standards 2012: ensuring patientcentered care. V1.2.1. www.facs.org/~/media/files/quality%20programs/cancer/coc/programstandards2012.ashx. Published 2012. Accessed August 4, 2015.
  10. Wolin KY, Colditz GA, Proctor EK. Maximizing benefits for effective cancer survivorship programming: defining a dissemination and implementation plan. Oncologist. 2011;16:1189-1196.
  11. Medicare.gov. Smoking & tobacco use cessation (counseling to stop smoking or using tobacco products). www.medicare.gov/coverage/smoking-and-tobacco-use-cessation. html. Accessed August 10, 2015.
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Last modified: September 18, 2015