Oncologists should intervene

We know that cigarette smoking is responsible for 30% of cancers in the United States. The article in this volume by Park et al highlights the critical importance of the clinician addressing tobacco cessation, particularly at the time of diagnosis. As one would expect, most patients with lung cancer have a history of smoking. Clinicians may be less aware of the data suggesting that there is a causal relationship between smoking and colorectal cancer. Greater than 58% of patients with colorectal cancer have a history of smoking, as compared with 42% in the general population. To prevent the 30% of cancers caused by tobacco use, we need to get better at preventing tobacco use initiation and promoting its cessation. However, this current paper highlights how critical it is for oncologists to address tobacco cessation with their patients—at the time of diagnosis. Most clinicians acknowledge the importance of addressing tobacco cessation in their patients; however, few do it.Most do not know how to do it—they did not receive this education inmedical school, nor did they receive focused tobacco use treatment training during residency or fellowship. Few physicians know of the US Tobacco Use Guidelines or the tobacco cessation Quitlines that are currently available in all 50 states and many countries. Oncologists should follow the protocol of the 2 A’s and R: Ask, Advise (ie, give the personalized message that stopping smoking is critical to the patient’s cancer treatment and survival), and Refer. The referral should be to an in-house tobacco cessation program or to a state (or national) Quitline. Tobacco use assessment and cessation should be performed by clinicians of all specialties in all patients primarily to prevent cancer, and secondarily to improve response and to prolong survival of patients already diagnosed with a cancer. Oncologists, however, perhaps need to be particularly focused on tobacco use cessation interventions. AdamGoldstein, MD, MPH surveyed 58 cancer centers throughout the United States (unpublished data) and demonstrated that less than half had a designated tobacco use treatment provider at their center. Thus, it seems that although oncologists know that a substantial proportion of their patients present with a tobacco-caused cancer, a substantial proportion of patients are still smoking at the time of diagnosis. There is much room for improvement for oncologists to more rigorously address tobacco cessation in their patients. In addition, it is critical to understand the risks of relapse; patients may stop smoking shortly before or at the time of diagnosis, but they are at a high risk of relapsing back to smoking during or after their treatment. By asking cancer patients at each visit, a relapse to smoking would be identified andmanaged, again by advising cessation and referring to an effective cessation program. Tobacco addiction is a relapsing chronic condition and should bemanaged as such. The risks of persistent smoking or relapse to smoking are well established for the cancer patient (see numerous other references within the Park et al paper). If we are to maximize the response to treatment with a consequent improved length and quality of survival, oncologists must address tobacco use in their patients. Dr. Park and her colleagues as well as others are researching evidence-based methodologies for oncologists to use in addressing tobacco use treatment in the cancer care setting. Cessation is possible, particularly with diagnosis-specific interventions. The US Tobacco Use Guidelines recommend the 5 A’s—Ask, Advise, Assess, Assist, and Arrange—as the basic outline for helping patients to quit tobacco. The first, Ask, is already frequently performed, but recorded with variable accuracy within the medical record. With upcoming implementation of meaningful use criteria—which will demonstrate that various electronic health data, including tobacco use, are recorded and integrated to improve care delivery— improvement in addressing cessation should occur. Oncologists should be able to routinely advise their patients to quit and not relapse— with personalization of the message. No matter the oncologic specialty (surgery, radiation,