Randomized trial of a presurgical scheduled reduced smoking intervention for patients newly diagnosed with cancer.

Continued smoking by tobacco dependent cancer patients is associated with greater risk of recurrence (Fleshner et al., 1999; Kenfield, Stampfer, Chan, & Giovannucci, 2011), reduced survival (Murin & Inciardi, 2001; Parsons, Daley, Begh, & Aveyard, 2010; Waggoner et al., 2006; Warren, Kasza, Reid, Cummings, & Marshall, 2012) and quality of life (Garces et al., 2004; Peppone et al., 2011); and an increased risk of peri-operative complications during treatment(Dresler, Bailey, Roper, Patterson, & Cooper, 1996; Moller, 2006; Theadom & Cropley, 2006; Warner, 2006). While cancer diagnosis is considered to be a “teachable moment” for smoking cessation (McBride & Ostroff, 2003) and often leads to spontaneous quitting, persistent smoking is a serious and prevalent clinical problem (IOM, 2012; Mayer & Carlson, 2011; Underwood, Townsend, Tai, et al., 2012). About 15.1% of all adult cancer survivors are current smokers (Underwood, Townsend, Stewart, et al., 2012). Persistent smoking among those who smoked prior to diagnosis varies widely by cancer type (Coups & Ostroff, 2005; Cox et al., 2002; Demark-Wahnefried, Aziz, Rowland, & Pinto, 2005; Gritz et al., 2006; Mayer et al., 2007; Ostroff et al., 2000; Park et al., 2012) with continued smoking rates ranging from a low of 20% among lung cancer patients(Cox et al., 2002) to a high of 65% among bladder cancer patients (Ostroff et al., 2000). Thus, cancer-specific health risks and the prevalence of persistent smoking argue for the importance of providing evidence-based treatment of tobacco dependence as a standard of quality care in cancer settings (American Society for Clinical Oncology, 2009; Cox, Africano, Tercyak, & Taylor, 2003; Fleshner et al., 1999; Gritz, Dresler, & Sarna, 2005; National Comprehensive Cancer Network, 2007). Smoking Cessation Trials with Cancer Patients Despite the serious risks of persistent smoking, there is little data on how best to promote cessation among cancer patients. Prior randomized controlled cessation trials of pharmacologic and counseling interventions conducted with cancer patients generally have not found statistically significant treatment effects, with 6-month point abstinence rates ranging from 14-30% among those in the intervention conditions (Nayan, Gupta, & Sommer, 2011). Given the acute and long-term risks and the high rates of persistent smoking, efficacious cessation interventions are needed for cancer patients (de Moor, Elder, & Emmons, 2008). The pre-hospitalization period represents a largely unexplored opportunity for smoking cessation treatment that can capitalize on oncologic providers' advice to quit and leverage a “teachable moment” for smoking cessation among tobacco dependent cancer patients (McBride & Ostroff, 2003). To date, no known trials have focused on preparing cancer patients to quit smoking prior to hospitalization. Scheduled Reduced Smoking (SRS) Scheduled reduced smoking (SRS) is a behavioral strategy for preparing to quit in which smokers gradually reduce their daily smoking rate by adhering to predetermined smoking times. Over days or weeks, the inter-cigarette intervals are gradually increased and smoking is delayed until the next scheduled cigarette. As the nonsmoking interval increases, smokers practice behavioral coping with smoking urges (Cinciripini, Wetter, & McClure, 1997). SRS may increase quitting self-efficacy as smokers experience less reward from smoking scheduled cigarettes and successfully manage smoking urges (Catley & Grobe, 2008). To date, two trials conducted with “healthy” smokers have shown that SRS is efficacious (Cinciripini et al., 1994; Cinciripini et al., 1995) with higher abstinence rates and greater coping with smoking urges and quitting self-efficacy for smokers using SRS than those who either quit abruptly, gradually reduced on their own, or smoked on a schedule without reduction (Cinciripini et al., 1995). SRS was chosen as a potential enhancement of the hospital's routine cessation treatment because of the promise of prior work, expectation that SRS would improve self-efficacy, and advantages of using a handheld computer for intervention delivery to reduce patient burden with clinic visits. The main study goal was to evaluate the efficacy of the SRS intervention combined with best practices (SRS+BP) when compared with BP alone (BP: cessation counseling and pharmacotherapy) on short- and long-term abstinence rates in smokers newly diagnosed with cancer and awaiting hospitalization for surgical treatment. It was hypothesized that patients assigned to the SRS+BP intervention arm would have higher rates of smoking abstinence than those who received BP alone.