Tobacco use is the leading cause of preventable morbidity and mortality in the United States, and almost 90% of all lung cancers are caused by smoking tobacco. The dangers of smoking are well documented; the harms extend beyond lung cancer surgery and impact the efficacy and tolerability of other treatments such as chemotherapy. While studies have shown that physicians in various healthcare settings can be trained to successfully deliver effective smoking cessation interventions, thoracic surgeons receive little training in this area of care. There are only a few prospective reports of tobacco cessation efforts involving thoracic surgeons in the current literature. However, thoracic surgeons do have a distinct advantage over other healthcare providers because they have an opportunity to take advantage of the “teachable moment” and capitalize on cessation efforts when meeting with patients preoperatively and during recovery.
Assessing a Brief Intervention
In the March 2010 Annals of Thoracic Surgery, my colleagues and I published a prospective study to evaluate a brief tobacco cessation intervention offered by surgeons in an outpatient thoracic surgery clinic. The primary outcome was abstinence at 3 months. Adult smokers were enrolled in a single-arm pilot trial in which they received a 10-minute intervention that included three components. The first component involved a brief motivational interviewing session in which patients were asked about what they enjoyed and didn’t enjoy about smoking, what (if any) strategies they’ve used in the past to quit smoking, and how they’d like to quit smoking. Patients were also informed of the importance of quitting their habit. The second component was offering tobacco cessation medication for which a one-page handout that described the available options was created. The third component involved promoting a free telephone quitline. A simple, user-friendly handout was also used to encourage use of this resource.
“Thoracic surgeons should seek to get more training
in smoking cessation efforts.”
Of the 40 patients who completed our study, the 3-month quit rate was 35% (14 of 40), and half of the study participants used at least one tobacco cessation medication. Only 7.5% (3 of 40) of patients called the quitline, but each of these participants quit smoking. The fact that tobacco cessation drugs and the quitline were underutilized emphasizes the need to educate people about valuable tools that can assist quit efforts. Successful tobacco cessation was associated with a malignant diagnosis and being the only tobacco user in the home. Patients receiving a lung cancer diagnosis were four times more likely to quit smoking than others; those who were the only smoker in the household were six times as likely to quit.
Needs for the Future
In light of our findings, our institution is planning a subsequent randomized control trial in which we will compare our intervention plus earlier follow-up by nurses to check about medication usage and encourage quitline use with another group that will receive a more intensive intervention. In the meantime, thoracic surgeons should seek to get more training in smoking cessation efforts. Free resources are available from the American Cancer Society, the Society of Thoracic Surgeons, the Department of Health and Human Services, and other well-respected organizations. Taking time to partake in these activities will enhance quit rates. Ultimately, the hope is that smoking cessation will become the sixth vital sign that is always checked during patient encounters.
Readings & Resources (click to view)
Kozower BD, Lau CL, Phillips JV, Burns SG, Jones DR, Stukenborg GJ. A thoracic surgeon–directed tobacco cessation intervention. Ann Thorac Surg. 2010;89:926-930. An abstract of the study is available at http://ats.ctsnetjournals.org/cgi/content/abstract/89/3/926.
Warner DO, Klesges RC, Dale LC, et al. Telephone quitlines to help surgical patients quit smoking patient and provider attitudes. Am J Prev Med. 2008;35(Suppl):S486-S493.
Arora R, Sowers JR, Saunders E, Probstfield J, Lazar HL. Cardioprotective strategies to improve long-term outcomes following coronary artery bypass surgery. J Card Surg. 2006;21:198-204.
Steinemann S, Roytman T, Chang J, et al. Impact of education on smoking cessation counseling by surgical residents. Am J Surg. 2005 Jan;189(1):44-6.
Warner DO, Sarr MG, Offord KP, Dale LC. Anesthesiologists, general surgeons, and tobacco interventions in the perioperative period. Anesth Analg. 2004;99:1766-1773.
Goldberg RJ, Ockene IS, Ockene JK, Merriam P, Kristeller J. Physicians’ attitudes and reported practices toward smoking intervention. J Cancer Educ. 1993;8:133-139.