Intensive Smoking Cessation Counseling for Patients With Cancer

“tobacco cessation after cancer diagnosis is often associated with improved quality of life, fewer complications related to cancer treatment, and longer survival. In a 2018 study, the prevalence of cigarette smoking among adult cancer survivors was 11.8%, and many cancer survivors who quit smoking after a diagnosis may resume smoking. Failure to address the unique challenges of cessation contributes to lack of success in initial cancer treatment due to ongoing smoking and has been associated with an estimated incremental cost of nearly $11,000 per year per smoking patient.

Tobacco abstinence is the strongest predictor of cancer survival, after cancer type and stage at the time of diagnosis.

[..] In this unblinded study conducted at 2 National Cancer Institute (NCI) Comprehensive Cancer Centers, the authors randomly assigned 303 patients with newly diagnosed cancer who smoked cigarettes to an intensive treatment group, with 4 weekly, 4 biweekly, and 3-monthly smoking cessation telephone counseling sessions coupled with 12 weeks of free cessation medication (either nicotine replacement therapy, bupropion, or varenicline) or to a standard treatment group, with 4 weekly telephone counseling sessions and medication advice, without provision of free medication. Intention-to-treat analysis of the 221 patients who completed the study (78.1% completion rate) showed that patients in the intensive treatment group achieved biochemically confirmed, higher 7-day abstinence rates at 6-month follow-up (34.5%) compared with patients in the standard treatment group (21.5%). While the 13% absolute between-group difference was slightly less than hypothesized, this difference may be clinically meaningful.

[..] It took the investigators almost 4 years to recruit the patients, and most of those screened for eligibility declined participation, suggesting potential barriers to broad uptake that warrant future implementation research. [..] In addition, the study did not measure cessation rates beyond 6 months, and relapse, even after 6 months of successful quitting, is not infrequent.

[..] Payers and health system leaders must acknowledge that current fee-for-service models for cancer treatment are incongruent with models of sustainable intensive smoking cessation counseling. Reimbursement for Medicare, Medicaid, and most private insurers only pays for 4 counseling sessions per quit attempt. Reimbursement in the fee-for-service model is based on evaluation and management physician billing codes for treatment, rather than certified tobacco treatment specialists who provide intensive counseling and use low reimbursement preventive counseling codes. Such codes do not incentivize additional counseling, and they do not reimburse at levels to sustain intensive programs. Given the cost-effectiveness of smoking cessation for patients with cancer and the consequences of failed treatment, value- and incentive-based reimbursements would potentially engender greater uptake of more intensive counseling from trained cessation therapists. If payers are willing to reimburse cancer centers thousands of dollars per patient annually for cancer treatments, they should be willing to invest in intensive cessation coverage, which ultimately lowers cost and improves outcomes.

Implementing intensive cessation counseling requires more than formulaic algorithms of treatment protocols. System-level change supported by patients, clinician groups, and cancer centers must occur, with provision of resources from payers and health care systems. In such an environment, clinicians can call on the best evidence from well-designed studies and use the art of medicine: the connection and empathy that foster patient trust and tailor treatments to each individual, devoid of stigma and judgment.”

Full editorial, Goldstein AO, Shoenbill KA and Jolly TA. JAMA 2020.10.13