Learning Objectives: 1. How did worldwide cigarette consumption change over the last 100 years? 2. Has the risk of lung cancer due to cigarette smoking changed over the last 50 years? Tobacco is the single most preventable risk to health worldwide according to the World Health Organization.1 The tobacco plant, Nicotiana tabacum/rustica, was first cultivated more than 3,000 years ago in Central America.2 The Spanish conquistadores brought tobacco to Europe. In 1559, it was planted in “Los Cigarrales”, Spain, from where it acquired its modern names cigars and cigarettes. Tobacco was very important for the economy of the US colonies. The agricultural needs of planting and harvesting tobacco determined much of the economy of the early colonies and is mentioned as a reason for slavery at that time.3 Tobacco was used up the late 19th century mainly in pipes, cigars, and chewable form. A change in curing the tobacco allowed more tobacco to be better tolerated when inhaled. Also, the invention of the safety match facilitated the increased use of cigarettes. The mass production of cigarettes started in the late 1800s after James Albert Bonsack (1859-1924) patented the cigarette-rolling machine in 1880. The cigarette-rolling machine was able to produce cigarettes 100-fold faster than manual cigarette rolling at that time (Figure 4-1). Figure 4-1. Bonsack’s machine for cigarette mass production (1882). Industrial mass production, helped by an effective marketing method, led to several tobacco producer monopolies. The US American Tobacco Company (ATC) combined several US companies, with Buck Duke as chairman, in 1889. The ATC then combined forces with the United Kingdom’s Imperial Tobacco to form British American Tobacco (BAT). BAT now is based in the United Kingdom and has the widest international network. Philip Morris started as a cigarette shop in the 1850s in London and transformed into multinational Altria, now among the largest tobacco companies, next to BAT, Japan Tobacco Industry, and state monopolies, such as China Tobacco. Cigarette consumption increased after 1900 and peaked in 1960 in the United States. There is a significant difference in tobacco use epidemiology between men and women and societies of different economic wealth4,5 (Figure 4-2). Figure 4-2. Prevalence of daily tobacco smoking. (Adapted with permission from World Health Organization (WHO). Global Status Report on Noncommunicable Diseases 2010. Geneva, Switzerland: World Health Organization; 2011. Copyright © World Health Organization 2011.) In the 20th century, tobacco caused the death of 100 million and is predicted to cause the death of a billion people in the 21st century.1,6 In 1949, Ernest Wynder and Evarts Graham published a case-control study in JAMA pointing at tobacco as a possible risk factor for lung cancer. In 1951 the British Medical Journal published a large epidemiologic study confirming tobacco as a significant risk factor for lung cancer. In 1964, Surgeon General Luther K. Terry published the first report on smoking warning about its risk.7 Over the following decades, more evidence was collected that smoking harms the secondhand smoker as well. In 1986, the surgeon general reported on the risk to secondhand smokers.8 In the 1990s, a master settlement enforced a penalty of billions of dollars on the tobacco industry. Despite all the educational efforts and regulatory barriers, tobacco consumption has significantly increased worldwide. Especially, countries and continents in the southern hemisphere have increased tobacco consumption and smoking by 300% to 1,400%.5 The major tobacco producers worldwide are presently China, 3 million tons per year; Brazil, 860,000 tons; India, 700,000 tons; and the United States, 400,000 tons in 2014. According to the Centers for Disease Control and Prevention (CDC), presently 15.5% of the adult US population smokes, and 16 million live with smoking-related diseases. Tobacco causes half a million deaths per year in the United States, of which 41,000 are due to secondhand smoking. Smokers on average died 10 years earlier than non-smokers. The US economic costs are approximately $300 billion. The average state tax in 2018 for a pack of cigarettes was $1.75. The smoking health costs and lost productivity per pack equals $19.16.9 A map of lung cancer mortality in the United States between 1980 in 2014 shows a significant variation in lung cancer deaths. The majority of lung cancer deaths occur in the Southeast and Midwest. Amazingly, in the last 30 years the death rate due to lung cancer has increased by up to 100% in some of these regions.10 There have been changes over time in the annual death rates from lung cancer and chronic obstructive pulmonary disease (COPD). Since 1964, at the time of the first surgeon general’s warning about smoking, there have been more than 20 million premature deaths attributable to smoking and secondhand smoke. Despite declines in the prevalence of current smoking, the annual burden of smoking-attributable mortality in the United States has remained above 400,000 for more than a decade and currently is estimated to be about 480,000, with millions more living with smoking-related diseases. The risk of dying of lung cancer per pack of cigarettes has doubled over the last 50 years (Figure 4-3). Figure 4-3. The increase in death rate of lung cancer in the last 40 years. (Reproduced with permission from US Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.) The annual burden of smoking-attributable mortality is expected to be at high levels for decades into the future, and 5.6 million youth are projected to die prematurely from a smoking-related illness. Smoking-attributable economic costs in the United States estimated for the years 2009-2012 were between $289 and $332.5 billion annually. This takes into account $132.5-$175.9 billion for direct medical care of adults and $151 billion for lost productivity due to premature death estimated from 2005 to 2009 and $5.6 billion (in 2006) for lost productivity due to exposure to secondhand smoke. Smoking remains the leading preventable cause of premature death in the United States and worldwide.11 In 1992, the Environmental Protection Agency (EPA) made tobacco a class A human lung carcinogen. This led to an effort to a ban smoking at the work place.8 A 55-year-old smoker of two packs a day asks you about smoking cessation. He has a history of seizures, COPD, and coronary artery disease (CAD). He has tried to quit smoking many times and never has been able to stop for more than 1 month. Learning Objectives: 1. What are the most efficient and effective ways to briefly address patients’ tobacco use? 2. What are the lesser-known aspects of over-the-counter (OTC) cessation pharmacotherapy product use? 3. What are the recommended approaches for those patients unwilling to quit smoking? 4. How do patients already diagnosed with lung cancer most benefit from cessation prior to or during treatment? 5. Which oncology treatment therapeutics are most affected by tobacco use and how? 6. Which resources are available to assist patients during their quit attempt? Luther L. Terry, MD, was the surgeon general of the US Public Health Service in 1964, and, perhaps unbeknownst to him or to many Americans at the time, he would become a critical figure in the history of both tobacco and lung cancer. Through the Surgeon General’s Advisory Committee on Smoking and Health, he released what is considered the first formal public report on the association between lung cancer and tobacco use on January 11, 1964. As per the CDC, this report was based on over 7,000 thousand articles that had already been published.12 The ramifications stemming from this report cannot be overstated. The National Clearinghouse for Smoking and Health was established less than 2 years later in September 1965 and would later be succeeded by the Centers for Disease Control and Prevention’s Office on Smoking and Health, with 29 additional reports on the health outcomes of cigarette smoking. In the political arena, the Federal Cigarette Labeling and Advertising Act and the Public Health Cigarette Smoking Act were adopted by the United States in 1965 and 1969, respectively. Laws were subsequently enacted that 1. Banned the use of advertising for cigarettes in broadcasting media 2. Requested annual reports on the consequences of smoking on health 3. Made a requirement for health warnings on cigarette packaging The history and study of tobacco and its association with lung cancer is not limited the United States or to the 20th century; in fact, there have been studies by countries all over the world. In the present day, for instance, data from the Swiss National Institute for Cancer Epidemiology and Registration (NICER) were extracted for gender- and age-specific rates of incidence for diagnosed cancers affecting the trachea, bronchi, and lungs between 1990 and 2014, along with smoking prevalence. Rates of cancer were decreased in men aged 40 to 44, 45 to 49, and 50 to 54, with a tendency toward decreasing rates in older cohorts. Authors conversely identified a higher smoking prevalence in younger as compared to older men born in the mid-1950s and 1960s. In women, cancer rates were increasing for those born from 1935 to the 1950s; increased smoking prevalence was seen in younger as compared to older women born in the mid-1960s. The authors concluded that an increasing incidence of lung cancer in young women was reflective of an evolving smoking epidemic and called for prevention strategies targeting young women.13 A modern application of these guidelines was summarized in a 2014 report by the surgeon general, which concluded that the risk of developing lung adenocarcinoma from smoking had increased since the 1960s, and that this increased risk was attributable to the changing composition and design of cigarettes. Speaking to this last point, the report further discussed that it was unclear which design changes had been responsible for this increased risk, but that increased tobacco-specific nitrosamines and ventilated filters were role players. Last, the report indicated that a decline in squamous cell carcinoma was correlated with a decline in the prevalence of smoking.14 Other countries are looking to the future in predictive analysis models. In August 2018, a group in South America published the results of an age-period-cohort analysis of patients in the National Cancer Registry of Uruguay between 1990 and 2014. A 70% risk reduction was seen in new cases of lung cancer in men born in 1970 compared to the early 1940s. In women, however, new diagnoses of lung cancer increased between 1991 and 2014, with specific increases in those born between 1940 and 1960. These trends were used to extrapolate data that predicted rates of new lung cancer diagnoses, which were calculated at 8% reduction in men but a 69% increase in females by 2035.15 Going forward, it is expected that studies similar to those performed in Switzerland and Uruguay will be expanded to other countries as researchers and public health entities around the world seek not only to explore the relationship between tobacco and lung cancer but also to reduce the global burden of cigarette smoking in the first place. The sustainment of tobacco use, and, as stated previously, increase of tobacco use in some populations is perhaps partially attributable to the various delivery systems that provide consumers with ease of use and even a sense of social belonging. It is not clear which of the numerous tobacco products that have emerged in more recent years may contribute more than others to lung cancer risk. But, since it is reasonable to consider all combustible forms of tobacco as sharing much of the same risk that is already well established with cigarette smoking, tobacco use by patients in any form should be determined. 1. Cigarettes. Although tobacco has been grown for consumption for centuries, a major milestone in the history of tobacco product manufacturing was the invention of a cigarette-rolling machine by James Bonsack in the late 19th century. In 1884, James Buchanan Duke would obtain the rights to this machine and, in the same year, began using it to manufacture cigarettes in Durham, North Carolina. Approximately 20 years later, in 1906, Duke convinced the US Congress to exclude tobacco from the Food and Drug Act. The Bonsack machine was capable of producing 120,000 cigarettes per day. By a comparison to modern times, the Hauni cigarette machine is currently capable of 20,000 cigarettes per minute.16 Today, almost 140 years later, the cigarette remains the most classic and recognizable form of tobacco use. 2. Cigars/cigarillos. Cigars are defined by the CDC as a rolled collection of tobacco wrapped within another tobacco-containing substance, such as a tobacco leaf. In the United States, cigar types are divided into large cigars, which contain approximately as much tobacco as a pack of cigarettes; cigarillos, which are 3-4 inches in length and do not traditionally have filters; and little cigars, which have filters and are similar in size to cigarettes. Of the cigar market share, 95% as of 2015 was occupied by large cigars and cigarillos. The cigar industry’s youth marketing focus increased in the 1990s, contributing to the nearly 8% of high school students who smoked cigars in 2017. In 2016, approximately 5% of US adults smoked cigars.17 3. Pipes. Pipe smoking is another form of tobacco use that is often compared to cigarette smoking in terms of safety. Seeking to answer this question, two researchers (Aage Tverdal and Kjell Bjartveit) conducted a prospective cohort study consisting of 16,932 men, age 20 to 29, across three Norwegian counties. These men were either exclusive users of pipe tobacco or had switched from exclusive cigarettes to exclusive pipe use. The authors found no significant difference in overall survival between exclusive cigarette and exclusive pipe users or in those who had transitioned from exclusive cigarette to exclusive pipe use.18 4. Hookah. Perhaps an even more well-known tobacco delivery system is the hookah, which consists of a head, long body, water bowl, and a mouthpiece connected to a hose, through which tobacco smoke is inhaled. Commonly used in small groups, the hookah is popular among youth. A 2010 study reported that, from a population of students in their final year of high school in the United States, 15% of girls and 17% of boys had used a hookah within a year of being surveyed. The percentage of college-aged students using a hookah was even higher, at 22%-40%.19 These statistics are unfortunate not only because of the high number of young users but also because of the physical amount of smoking involved in hookah smoking. To compare, approximately 500-600 mL smoke are inhaled over 20 puffs taken in smoking a single cigarette, while 90,000 mL are inhaled over 200 puffs taken in an average hookah session.20–22 5. Bidis, kreteks. Other forms of tobacco delivery, although low in prevalence, are important to be aware of, as they pose similar health risks to those of cigarettes. Smoking bidis, for example, which are hand-rolled cigarettes imported from India and other parts of Southeast Asia, increase the risk of both lung and oral cancer.23–28 Kreteks, which come from Indonesia and are known as clove cigarettes because they contain cloves as well as additives, have been shown in regular users to increase the risk for either reduced absorption of oxygen or obstruction of airflow by a factor of 13 to 20. By comparison to the traditional US cigarette, kreteks and bidis are both more highly concentrated with carbon monoxide, tar, and nicotine.23,26,29,30 6. Smokeless/spit tobacco. Smokeless tobacco, such as that which is placed in the buccal mucosa or chewed in the mouth and later disposed of (thus referred to as “chewing tobacco”), has the high potential for nicotine addiction and has been demonstrated to cause oral as well as esophageal cancer.11,31 As of 2016, approximately 3.4% of persons greater than 18 years old (6.6% of men and 0.5% of women) in the United States were current users of smokeless tobacco. Demographically, American Indians/Alaskan Natives (non-Hispanic) were the most common consumers at 8.4%.32 7. E-cigarettes/vaping devices. The final category of tobacco delivery systems, electronic cigarettes (e-cigarettes), has gained national attention in the United States in recent years, specifically because of the staggering number of young users. Often referred to as “vaping,” electronic cigarettes are small devices that come in various structures that serve to heat a nicotine-containing liquid, which is then aerosolized and inhaled.33 As of 2018, within 30 days of being surveyed, 20.8% of students in US high schools (generally age 14-18) and 4.9% in middle schools (age 10-14) had used an e-cigarette, amounting to 3.6 million users in these age groups.34 Another interesting and unfortunate point about e-cigarettes is that, for many persons, their intended utility is to wean off of and eventually quit smoking standard tobacco-containing cigarettes. The issue, however, is that adults attempting this method are often smoking cigarettes concurrently in a practice known as “dual use.”25,26,35,36 Moreover, it is important to note that the US Preventive Services Task Force determined in a 2015 synthesis that there was insufficient evidence in both pregnant women and adults for the use of e-cigarettes in smoking cessation.37 According to the CDC, the percentage of adults (meaning age ≥ 18 years) in the United States decreased from 20.9% in 2005 to 15.5% in 2016. However, almost 38 million adults are smoking a cigarette at least some days but up to every day.38 By state, Kentucky, Louisiana, and West Virginia have the highest prevalence, with 22.9%-26.4% of their population smoking cigarettes. They are closely followed by several other states, whose percentages range between 19.4% and less than 22.9%; these states include Alabama, Alaska, and Ohio.39,40 A depiction of smoking prevalence across the entire United States is shown in Figures 4-4 (adults) and Figure 4-5 (youth). Figure 4-4. Map of the United States, with states differentially shaded by prevalence of cigarette use in adults. (From Centers for Disease Control and Prevention. Map of Current Cigarette Use Among Adults 2018. https://www.cdc.gov/statesystem/cigaretteuseadult.html. Accessed April 21, 2019.) Figure 4-5. Map of the United States, with states differentially shaded by prevalence of cigarette use among youth. (From Centers for Disease Control and Prevention. Map of Current Cigarette Use Among Youth. 2018. https://www.cdc.gov/statesystem/cigaretteuseyouth.html. Accessed April 21, 2019.) The high prevalence of cigarette usage in the United States does not reflect a lack of desire or active effort to quit smoking. In 2015, for example, approximately 68% of adults who used cigarettes wanted to engage in smoking cessation, and 54% had attempted smoking cessation within 1 year of being surveyed.41 Regarding successful quit attempts, researchers from the University of San Diego School of Medicine and Moores Cancer Center reported an annual smoking cessation rate of approximately 4.5% among active American smokers up to 2013-2014. This value increased to 5.6% in 2014-2015, which the authors attributed to a high rate of electronic cigarette use (49.3%) in persons who had recently quit successfully.42 According to the National Cancer Institute (NCI), “On average, current smokers have approximately 20 times the risk of lung cancer compared with nonsmokers.” Tobacco smoking is estimated to cause 90% of lung cancer in males and 78% in females. Cigar and pipe smoking are also associated with increased lung cancer risk.43 Occupational carcinogens, including asbestos, radon, tar, and soot (sources of polycyclic aromatic hydrocarbons), and arsenic, chromium, nickel, beryllium, and cadmium are estimated to cause 10% of lung cancers. When cigarette smoking is added to radon or asbestos exposure, the combination interacts synergistically to increase the risk of lung cancer development, resulting in a risk much higher than the sum of the risks associated with each factor alone.43,44 Radon exposure is the leading cause of lung cancer in those who have never smoked cigarettes. A radioactive gas emitted from uranium in the soil, radon can become trapped in homes and other buildings, with the potential for reaching elevated levels equivalent to 200 chest x-rays a year. Since radon is invisible, odorless, and tasteless, the only way to know if there are elevated levels is by employing a test kit from a state radon program or home improvement store; a home can also be tested by a certified radon mitigation contractor. The EPA has categorized radon as a class A carcinogen and considers elevated levels to be those above 4 picocuries/liter of air.43 Given the possible role radon may have had in the development of lung cancer in a person without a history of tobacco use or significant occupational carcinogen exposure (eg, asbestos), clinicians should recommend radon testing to patients and those living with them. This will prevent further risk not only to the patient but also to others who have been exposed. The potential impact of smoking cessation on lung cancer rates has been studied for years across multiple nations. Researchers in the year 2000, for example, published a study in the British Medical Journal reporting on smoking and smoking cessation trends in relation to lung cancer in the United Kingdom; the study was based on a summary of studies from 1950 to 1990. Smoking prevalence decreased by 50% from 1950 to 1990 in “early middle age” men, while rate of death in those aged 35 to 54 declined even more significantly. Higher rates of lung cancer were expectedly seen in older men and women who had persistently smoked throughout their adult lives. Assuredly, however, both women and men in 1990 who were designated as former smokers had lower cumulative risk of lung cancer than those who had continually smoked since 1950. Cumulative risk, moreover, declined with increased duration of smoking cessation. Results from this study are depicted in Figure 4-6.6 Figure 4-6. Cumulative risk of lung cancer by duration of smoking cessation. (From Inamura K, Ninomiya H, Nomura K, et al. Combined effects of asbestos and cigarette smoke on the development of lung adenocarcinoma: different carcinogens may cause different genomic changes. Oncol Rep. 2014;32(2):475-482.) In similar research conducted as part of the Singapore Chinese Health Study in 2010, regarding risk of lung cancer, a 28% reduction was observed in patients who had quit smoking relative to current smokers.45 An even more recent 2015 study examined a US population of nearly 150,000 patients. Relative to never-smokers, the hazard ratio was substantially greater in those whose years since quitting (YSQ) was less than 5 at a hazard ratio of 30.8 than in those whose YSQ was greater than 30 at a 6.4 hazard ratio.46 Despite potential for improved lung cancer survival due to recent treatment advances and the ability to detect lung cancer earlier through the use of low-dose computed tomographic (LDCT) scans, smoking cessation still has the ability to prevent more lung cancers and resulting deaths than any other approach. Most smokers are fully aware that smoking is harmful to their health and can cause lung cancer. This points to the fact that knowledge of the risk is not what can make a significant impact on smoking behavior. The reality is that cigarettes are extremely addictive and keep people using a product that in many cases they cognitively and rationally want to stop using. Nicotine addiction is referred to by experts as a chronic brain disorder.47 Tobacco use moreover is sometimes cast as a bad or even unsightly habit, which places an unfortunate stigma on cigarette consumers because a major driving force for use is not personal weakness, but rather physiological addiction. Once cigarette smoke is inhaled and carried into the lungs, nicotine enters the pulmonary venous circulation, ultimately leading to the delivery of nicotine to the brain in as few as 11 seconds or less. Here, nicotine binds to acetylcholine receptors, which opens ligand-gated channels to allow for the entry of calcium and sodium into neurons, an action that subsequently releases neurotransmitters into the brain. Among these neurotransmitters is dopamine, which results in a sensation of pleasure.48 These same nicotinic cholinergic receptors, termed nicotinic acetylcholine receptors, or nAChRs, are actually upregulated by cigarette smoking, specifically the α4β2*nAChR subtype. Cigarette smokers with less upregulation of α4β2*nAChR have a higher likelihood of complete smoking cessation.49 Neurochemical and related effects include the following: These effects collectively provide significant reinforcement for continued tobacco use.50 Eighty percent of tobacco users initiate smoking by the age of 18. Of this population, between 20% and 25% of consumers will then become dependent on daily smoking in adulthood. It is common for adolescents to believe that a small amount of tobacco use will not be addicting, that they can quit at any time when ready, and that the long-term consequences of smoking will not befall them. Lung cancer is one of the potential consequences that, when it happens, will likely be decades after smoking initiation, so it is therefore not of much concern to an adolescent. For this reason, some have even considered lung cancer a pediatric disease given when the most predominant cause actually originated for the patient. Unfortunately, addiction to tobacco is even more common in persons with disorders of substance abuse or general mental health, with such individuals smoking approximately 40% of all cigarettes consumed in the United States.48,51 The tobacco industry has not missed the opportunity to take advantage of such populations and have in fact crafted directives to specifically target homeless, mentally ill, lesbian, gay, bisexual, and transsexual persons, such as Project Sub Culture Urban Marketing, or SCUM, which in the 1990s was introduced to San Francisco.51 In relation to other substances, tobacco smoking has been demonstrated to increase craving for both heroin and cocaine, and the research group that reached this conclusion in 2010 suggested that treatment for heroin and cocaine dependence should be conducted in conjunction with tobacco cessation counseling, so as to treat the addictive process itself rather than addiction to individual substances.52 And fortunately, modern medicine has made tremendous advances in smoking cessation with nicotine replacement therapy (NRT), making tobacco cessation for such patients a distinct and attainable goal. NRT releases small amounts of nicotine into the systemic circulation while removing the tar burden brought forth by smoking tobacco-laden cigarettes. Varenicline serves as a partial α4β2*nAChR agonist, thus delivering similar effects of nicotine without the harmful effects of inhaled cigarette smoke.53 Scientists are now taking the study of tobacco cessation even deeper and have developed the nicotine metabolite ratio, which is a phenotypic index of nicotine metabolism that serves to guide clinicians in selecting the most appropriate form of cessation therapy for their patients. In slow nicotine metabolizers, for example, NRT is most appropriate. Those who metabolize nicotine at a normal rate, however, are better candidates for non–NRTs, such as varenicline.54 NRT is discussed further in this chapter. Approximately 70% of patients want to quit smoking when asked, but unfortunately 95% of attempts that are unassisted by supportive counseling and therapies will result in failure. Poor medication adherence is a major cause, as is poor attendance at counseling sessions.55 Most clinicians have not received substantial, if any, training prior to their medical practice about evidence-based recommendations for treating tobacco use. To address this by providing essential guidance for clinicians in practice, the Public Health Service (PHS) Treating Tobacco Use and Dependence Clinical Practice Guideline (TTUD-CPG) was published in 2008, along with a Quick Reference Guide that provided key recommendations for providers, with these recommendations based on a summary from decades of research and cumulative analysis.56 Time is a big limitation for all clinicians, and a common perception is that cessation counseling can be very time consuming. The TTUD-CPG states that clinicians can be effective with patient cessation in as little as 3 minutes. More specifically, the likelihood that a patient will quit is increased by 40% with a 1- to 3-minute intervention. If 30 minutes of counseling is provided, even over multiple visits, that likelihood increases to 90%.14 Clinician intervention in treating tobacco use and dependence can be powerful and have a significant impact, even more substantial than that of family members. The so-called white coat effect reinforces the influential role of a health care professional. Adopting use of the TTUD-CPG tool would be of specific benefit to the many clinicians who have attempted counseling but have been unsuccessful in guiding patients to full cessation. Following the guideline’s recommendations would also improve efficiency by implementing approaches proven to be effective. Last, when clinicians do not ask about tobacco use or assist with cessation, the patient can perceive this as their tobacco use not being a priority or posing a significant threat to their health. Since patients are typically aware that smoking is bad for them on some level and that they should quit, if not addressed, they could question the quality of care they are receiving in general. The ideal approach in managing smoking cessation, particularly for providers, involves multiple individuals working together as a comprehensive care team to perform tobacco use assessment, provide counseling and assistance for patients, and ensure follow-up. This team should include nurses, pharmacists, tobacco education specialists (if available), and care coordinators. The team approach serves two purposes, one being the time-saving effect for providers, who can then direct more attention to patient care and counseling, and the other being a reinforcement of important topics by multiple team members, which patients are then likely to interpret as points to commit to memory and to actual practice. The TTUD-CPG recommends using the following five A’s for patients, especially those willing to quit: Ask about all tobacco use Advise patients to quit Assess willingness to quit Assist in developing a quit plan Arrange for patient follow-up Appropriate wording of questions by clinicians can have an impact on the thoroughness and accuracy of patient responses. It is best, for example, to avoid labeling an individual with the term smoker and keep wording limited to the behavior alone. Asking about cigarette/tobacco use in the last month/30 days helps to avoid reports of temporary smoking status based on exceptional circumstances, like being sick or having just attempted quitting in the days leading up to the visit. While it is always important for clinicians to have tobacco use documented, a verbal detailed assessment provides a valuable opportunity to discuss various aspects of the patient’s tobacco use and for the patient to elaborate on their written response given on a form. A paper-based questionnaire, for example, ideally should ask about all forms of tobacco and/or electronic cigarette use in the prior 30 days, including quantity (ie, how many packs/day), how often, and whether or not any pharmacologic or non-pharmacologic methods of cessation are being utilized. A discussion of use pattern as well as history of attempted cessation should then follow, particularly if the patient is still using tobacco. Electronic medical record systems are also helpful here, as clinicians can enter patients’ responses directly into automated programs that prompt the user with related questions. These responses can then be examined at future visits for comparisons and progress updates. When approaching patients with specific questions about qualitative and quantitative tobacco use, it is best to maintain a neutral, non-judgmental demeanor and to remain as objective as possible. The types of questions discussed next should be included in the initial evaluation of each patient. First, ask about which type of tobacco or device(s) the patient is currently using or has used since there are many tobacco products other than cigarettes, such as those mentioned previously in this chapter, as well as an array of vaping products, which are considered tobacco products by the Food and Drug Administration (Food and Drug Administration) and may contain nicotine. And interestingly, since tobacco smoke could interact with various therapies (as shown in Table 4-1), if the patient is taking any of the medications listed, this potential impact should be explained to the patient as another incentive for cessation. The most significant interactions are highlighted in gray.57,58 TABLE 4-1 Interactions Between Various Medications and Tobacco Smoke
4
TOBACCO AND LUNG CANCER
HISTORY OF TOBACCO
PREVALENCE OF SMOKING
SURGEON GENERAL REPORT 2014
CONTROL OF TOBACCO
INTERNATIONAL TOBACCO CONTROL
TYPES OF TOBACCO AND E-CIGARETTES
US CURRENT SMOKING STATISTICS
TOBACCO’S SYNERGISTIC RISK FOR LUNG CANCER
LUNG CANCER PREVENTION AND TOBACCO CONTROL
TOBACCO AND NICOTINE ADDICTION
Nicotine Replacement Therapy
CHALLENGES IN SMOKING CESSATION
The Patient’s Challenge
Challenges to Clinician Intervention
Benefits of Clinician Intervention
Engaging Multiple Caregivers
PATIENT COMMUNICATION IN TREATING TOBACCO USE DISORDER
The Five A’s Model
General Approach to Questioning
Assessing Patient Tobacco Use and Dependence: Ask
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