Abstract
Introduction
Tobacco use is associated with poor outcomes in cancer patients, but there is little information on the practice patterns or perceptions of tobacco use and smoking cessation by oncology providers.
Methods
An online survey of practices, perceptions, and barriers to tobacco assessment and cessation in cancer patients was conducted in members of the International Association for the Study of Lung Cancer (IASLC). Responses of physician level respondents were analyzed and reported.
Results
Responses from 1,507 IASLC members who completed the survey are reported representing 40.5% of IASLC members. Over 90% of physician respondents believe current smoking affects outcome and that cessation should be a standard part of clinical care. At the initial patient visit, 90% ask patients about tobacco use, 79% ask patients if they will quit, 81% advise patients to stop tobacco use, but only 40% discuss medication options, 39% actively provide cessation assistance, and fewer yet address tobacco at follow-up. Dominant barriers to physician cessation effort are pessimism regarding their ability to help patients stop using tobacco (58%) and concerns about patient resistance to treatment (67%). Only 33% report themselves adequately trained to provide cessation interventions.
Discussion
Physicians who care for lung cancer patients recognize the importance of tobacco cessation as a necessary part of clinical care, but many still do not routinely provide assistance to their patients. Increasing tobacco cessation will require increased assessment and cessation at diagnosis and during follow-up, increased clinician education, and improved tobacco cessation methods.
Keywords: smoking, tobacco, survey, thoracic, oncologists, cancer, cessation
Introduction
Incorporation of standardized tobacco use assessments into clinical practice has been advocated for several years but is not widely practiced. Many health care providers who treat cancer patients may assume that it is too late after diagnosis to intervene with cancer patients. However, continued smoking has an adverse effect on cancer patients through increased complications from surgery, increased treatment-related toxicity, increased risk of recurrence, increased risk of second primary tumors, increased non-cancer related comorbidity and mortality, and decreased survival (1–7). Smoking after diagnosis also decreases quality of life for both cancer patients and caregivers for patients with lung or colorectal cancer (8). There are limited studies on the effects of smoking cessation in cancer patients, but data suggest that the effects of smoking are reversible (7,9–12). These data support the incorporation of smoking cessation as standard clinical treatment for cancer patients.
The International Association for the Study of Lung Cancer (IASLC) is the only global organization dedicated to the study and treatment of lung cancer. Founded in 1974, the association’s membership includes more than 3,500 multi-disciplinary lung cancer specialists in 80 countries. IASLC members work to enhance the understanding of lung cancer among scientists, members of the medical community and the public. Because tobacco smoking is such an important cause of lung cancer worldwide, IASLC continues to advocate for policies that discourage the use of tobacco and works to educate its membership about the importance of counseling patients to stop smoking. This paper presents the results of an online survey of IASLC members conducted in 2012 to assess the tobacco assessment and cessation practices of members and to identify perceptions and potential barriers to implementing tobacco cessation interventions for cancer patients.
Materials and Methods
The study was approved by the Institutional Review Board at Roswell Park Cancer Institute (Buffalo, NY). A brief online questionnaire was developed to assess IASLC member practice patterns and perceptions regarding tobacco use among cancer patients. The online survey included questions asking about respondent background characteristics (i.e. educational degree, area of clinical practice, primary work setting, percentage of time devoted to patient care, and years since completion of a “most senior degree”) and questions to assess frequency of assessing tobacco use and providing tobacco cessation support at initial patient visit, frequency of assessing tobacco use at follow-up appointments, perceived barriers to providing tobacco cessation interventions for cancer patients, and opinion/judgment statements on the relationship between tobacco and cancer. In addition, the survey asked about prior and current tobacco use of respondents as well as the country where the respondent practices. The full questionnaire is available in Supplementary Appendix I.
The survey was distributed to the membership of IASLC using an online survey. The survey was resent 4 times over a 6-week period of time as a means to increase participation. Respondents were incentivized by enrollment in a drawing to win a free Ipad (Apple Inc.) sponsored by IASLC. The survey was online via email contact and annotated answers were collated for analysis. Of 3,719 IASLC members invited to participate, 1,507 (40.5%) completed the survey for this analysis.
Data Analysis
Analyses were restricted to respondents who reported having a medical degree (or equivalent) and who provided clinical care for cancer patients. Respondents who fit these criteria represent 87% of total survey respondents. Data were transferred to SAS 9.3 software for statistical analyses. The results presented were primarily based upon descriptive analyses. Demographic variables were grouped for comparison between respondents and non-respondents to assess whether respondents constituted a representative sample. Degrees were separated into Medical Degree, Higher Science Degree, Basic Science Degree, Nursing, and Pharmacy. Specialty (i.e. primary area of clinical practice) was separated into Surgery, Medical Oncology, Radiation Oncology, Pulmonary Medicine (including Pulmonology, Respirology, and Pneumonology), and Other. There were several countries of origin that were grouped according to frequency of response. Countries representing less than 4% of responses (i.e. with fewer than 60 respondents in a country) were grouped according to continent. Australia, Canada, China, Japan, United Kingdom and United States were countries with at least 60 respondents.
Respondent smoking history questions were combined to form one variable to represent smoking status. Respondents who answered the question ‘Do you now smoke cigarettes every day, some days, or not at all?’ with ‘Every day’ or ‘Some days’ were considered current smokers. Respondents who answered ‘Not at all’ to this question and stated that they had smoked at least 100 cigarettes in their life were categorized as former smokers. Respondents who answered ‘Not at all’ to the smoking status question and ‘No’ to at least 100 cigarettes smoked during their lifetime were considered never smokers.
Comparison of respondent and non-respondent characteristics was used to gauge possible response bias. The significance of difference was assessed by the chi-squared test. Comparisons were based upon academic degree, specialty, and country of practice since these variables were available for all potential survey participants.
Results
The characteristics of the respondents and non-respondents are shown in Table 1. Respondents did differ from non-respondents with regards to degree, specialty, and country. IASLC members outside of the United States were more likely to respond to the survey than those from the United States. In addition, surgeons and medical oncologists were more likely to respond compared to other specialties, though the differences were slight. Medical oncology represents the primary respondent category (33%), most respondents have a medical degree (87%), and 51% are from the United States or Europe.
Table 1. Respondent characteristics.
Characteristics for respondents and non-respondents are shown. Significant differences between respondents and non-respondents for each category was calculated using Chi-squared with significance determined at p<0.05. Abbreviations: MD (medical doctorate), USA (United States of America).
| Category | Respondents (%) | Non-respondents (%) | P value | |
|---|---|---|---|---|
| Overall | 1507 (40.5) | 2212 (59.5) | ||
| Specialty | Medical Oncology | 504 (33.4) | 582 (26.3) | <0.001 |
| Pulmonary Medicine | 282 (18.7) | 430 (19.4) | ||
| Radiation Oncology | 133 (8.8) | 242 (10.9) | ||
| Surgery | 366 (24.3) | 445 (20.1) | ||
| Other | 222 (14.7) | 513 (23.2) | ||
| Degree | Science | 103 (6.8) | 206 (9.3) | <0.001 |
| MD | 1306 (86.7) | 1947 (88.0) | ||
| Nursing | 37 (2.5) | 20 (0.9) | ||
| Other | 61 (4.0) | 39 (1.8) | ||
| Country | Australia | 88 (5.8) | 83 (3.8) | <0.001 |
| Canada | 60 (4.0) | 63 (2.8) | ||
| China | 68 (4.5) | 45 (2.0) | ||
| Japan | 181 (12.0) | 316 (14.3) | ||
| United Kingdom | 68 (4.5) | 87 (3.9) | ||
| United States (USA) | 343 (22.8) | 629 (28.4) | ||
| Africa | 22 (1.5) | 13 (0.6) | ||
| Asia (excluding Japan and | 131 (8.7) | 229 (10.4) | ||
| China) | ||||
| Europe | 431 (28.6) | 674 (30.5) | ||
| North America (excluding | 13 (0.9) | 14 (0.6) | ||
| Canada and USA) | ||||
| South America | 90 (6.0) | 59 (2.7) | ||
| Other Countries | 12 (0.8) |
Table 2 shows the practice characteristics and tobacco use history of the 1,304 MD-level respondents. Most respondents reported that they practice medicine in a university or academic setting (70%), most have been in practice for more than 10 years (73%), and most reported spending at least 50% of their time devoted to patient care (77%). Whereas 70% of respondents reported a never smoking history, there were 69 MD respondents (5%) who reported current tobacco use.
Table 2.
Practice and tobacco use characteristics from physician respondents.
| Category | Frequency (%) | |
|---|---|---|
| Work setting | University or Academic | 914 (70.1) |
| Hospital Based non-Academic | 294 (22.5) | |
| Other | 96 (7.4) | |
| Years passed since completion of terminal degree | Still enrolled or less than one year | 24 (1.8) |
| 1–5 years | 98 (7.5) | |
| 6–10 years | 233 (17.9) | |
| 11–20 years | 421 (32.3) | |
| 20+ years | 528 (40.5) | |
| Tobacco use history | Current smoker | 69 (5.3) |
| Former smoker | 314 (24.1) | |
| Never smoker | 915 (70.2) | |
| Other | 6 (0.5) | |
| Percent of time devoted to patient care | 0% | 33 (2.5) |
| 1–24% | 69 (5.3) | |
| 25–49% | 193 (14.8) | |
| 50–74% | 553 (42.4) | |
| 75–100% | 456 (35.0) |
Tobacco use assessment is reported in Table 3. At the initial patient visit, the overwhelming majority of respondents reported that they ask patients if they use tobacco (90% ask always or most of the time), ask patients if they will quit (79% ask always or most of the time), and advise patients to stop tobacco use (81% advise always or most of the time). However, a lower percentage reported discussing medication options (40% always or most of the time) and actively treating patients (39% always or most of the time). Questioning about tobacco use at follow-up was less frequently reported.
Table 3.
Frequency of physician interactions with patients.
| During an Initial Visit | ||||||
|---|---|---|---|---|---|---|
| Question | Always (%) | Most of the Time (%) | Some of the Time (%) | Rarely (%) | Never (%) | N/A (%) |
| Ask patients if they smoke or use tobacco products | 927 (70.4) | 260 (19.8) | 36 (2.7) | 9 (0.7) | 4 (0.3) | 80 (6.1) |
| Ask people who smoke or use tobacco if they will quit tobacco use | 656 (49.9) | 382 (29.0) | 143 (10.9) | 41 (3.1) | 17 (1.3) | 77 (5.9) |
| Advise people who smoke or use tobacco products to stop smoking | 659 (50.1) | 402 (30.5) | 136 (10.3) | 30 (2.3) | 11 (0.8) | 78 (5.9) |
| Discuss medication options such as nicotine replacement, bupropion, varenicline, etc. | 207 (15.7) | 323 (24.5) | 426 (32.4) | 223 (16.9) | 52 (4.0) | 85 (6.5) |
| Actively treat or refer patients for smoking/tobacco use cessation intervention | 229 (17.4) | 282 (21.4) | 386 (29.3) | 243 (18.5) | 80 (6.1) | 96 (7.3) |
| During Follow-Up Appointments | ||||||
| Always (%) | Most of the Time (%) | Some of the Time (%) | Rarely (%) | Never (%) | N/A (%) | |
| Ask patients about current smoking or tobacco use | 547 (41.6) | 420 (31.9) | 209 (15.9) | 38 (2.9) | 12 (0.9) | 90 (6.8) |
| Ask patients if they have quit smoking or stopped using tobacco | 514 (39.1) | 428 (32.5) | 235 (17.9) | 39 (3.0) | 11 (0.8) | 89 (6.8) |
| Ask patients if they have relapsed back into tobacco use | 422 (32.1) | 403 (30.6) | 283 (21.5) | 101 (7.7) | 19 (1.4) | 88 (6.7) |
| Reinforce the importance of stopping tobacco use | 496 (37.7) | 435 (33.1) | 228 (17.3) | 56 (4.3) | 14 (1.1) | 87 (6.6) |
Respondent opinions on tobacco use in cancer patients are shown in Table 4. A large proportion of respondents reported believing that current smoking by cancer patients affects outcomes (92% agree or strongly agree) and that tobacco cessation should be a standard part of clinical care (90% agree or strongly agree). In contrast, only 33% of respondents agreed or strongly agreed that they have had adequate training in cessation interventions and 82% agreed that clinicians need more training in tobacco assessment and cessation.
Table 4.
Physician respondent opinions on tobacco use and cancer.
| Question | Strongly Agree (%) | Agree (%) | No opinion or neutral (%) | Disagree (%) | Strongly Disagree (%) |
|---|---|---|---|---|---|
| Current smoking or tobacco use impacts treatment outcomes in cancer patients | 561 (43.0) | 636 (48.7) | 75 (5.7) | 27 (2.1) | 7 (0.5) |
| Tobacco cessation should be a standard part of cancer treatment interventions | 603 (46.2) | 575 (44.0) | 93 (7.1) | 28 (2.1) | 7 (0.5) |
| I have had adequate training in tobacco cessation interventions | 81 (6.2) | 346 (26.5) | 367 (28.1) | 430 (32.9) | 82 (6.3) |
| Clinicians need more training in tobacco assessment and cessation interventions | 290 (22.2) | 785 (60.1) | 162 (12.4) | 61 (4.7) | 8 (0.6) |
| I believe tobacco smoking is the primary cause of the current lung cancer burden | 719 (55.1) | 478 (36.6) | 81 (6.2) | 23 (1.8) | 5 (0.4) |
Barriers to providing cessation interventions are reported in Table 5. Most respondents reported that inability to get patients to quit (58%) and patient resistance to treatment (67%) were barriers to cessation interventions in cancer patients. Nonetheless, only 12% believed that cessation is a waste of time. Lack of training or experience (48%), lack of available resources (48%), and lack of time (45%) were also endorsed as barriers to providing cessation.
Table 5.
Physician respondent perceptions of barriers to providing tobacco cessation interventions in cancer patients who currently smoke or use tobacco.
| Question | Strongly Agree (%) | Agree (%) | No opinion or neutral (%) | Disagree (%) | Strongly Disagree (%) |
|---|---|---|---|---|---|
| Inability to get patients to quit tobacco use | 154 (11.7) | 615 (46.7) | 266 (20.2) | 212 (16.1) | 69 (5.2) |
| Waste of time – cessation does not affect outcomes in cancer patients | 18 (1.4) | 138 (10.5) | 150 (11.4) | 491 (37.3) | 519 (39.4) |
| Lack of time for counseling or to set up a referral | 69 (5.2) | 523 (39.7) | 295 (22.4) | 321 (24.4) | 108 (8.2) |
| No or limited provider reimbursement | 68 (5.2) | 342 (26.0) | 485 (36.9) | 291 (22.1) | 130 (9.9) |
| Patient resistance to cessation treatment | 166 (12.6) | 720 (54.7) | 218 (16.6) | 172 (13.1) | 40 (3.0) |
| Lack of training or experience in tobacco cessation interventions | 68 (5.2) | 559 (42.5) | 313 (23.8) | 299 (22.7) | 77 (5.9) |
| Lack of available resources or referrals for cessation interventions | 99 (7.5) | 526 (40.0) | 260 (19.8) | 339 (25.8) | 92 (7.0) |
Discussion
These data suggest that although thoracic oncology physicians view tobacco use as affecting cancer outcomes and that tobacco cessation should be a standard part of clinical cancer treatment, they also believe that cancer patients are unable to stop tobacco use. According to these data, physicians frequently “ask” and “advise”, but infrequently “assist” with tobacco cessation. Data further suggest that physicians do not feel adequately prepared to deliver effective tobacco cessation support to their cancer patients; however, only 12% of respondent IASLC physician members believe that smoking cessation is a waste of time.
Similar practice patterns for lung cancer patients have been noted in smaller studies. According to a survey of 71 thoracic oncologists, 61% of providers did not provide cessation assistance for metastatic lung cancer patients (13). In a survey of 74 oncology providers, 82.4% assessed tobacco at initial visit, but only 42.5%–60.8% assessed tobacco at follow-up, fewer than 30% provided assistance with quitting (referral to cessation service, nicotine replacement, withdrawal assistance, or self-help materials) and 51.1% requested additional training in smoking cessation “quite a bit” or “very much” (14). Notably, 87.8% of respondents reported “Patients lack motivation to quit” and 84.7% reported “Patients do not see quitting smoking as an immediate concern” as barriers to implementing smoking cessation. Inadequate time (27% of respondents) and lack of reimbursement (9.6% of respondents) were minor barriers to implementation (14). Our findings parallel these trends. Both studies demonstrated remarkably high levels of concern for tobacco use in cancer patients, but low levels of physician assistance for tobacco cessation. These data suggest that even among very motivated practitioners, there are significant deficits in providing cessation support to cancer patients.
The importance of the oncology physician in promoting tobacco cessation has been emphasized in several reports. Among head and neck cancer patients, a doctor’s advice was shown to be an important patient perceived reason for smoking cessation (15) and counseling at the time of diagnosis improves cessation rates (16). However, in the randomized trial of usual care vs. a physician led smoking cessation in 432 cancer patients from several cancer sites, a physician led intervention did not improve 7-day point prevalence defined cessation at 12 months (17). Notably, patients with lung or head/neck cancer had a higher likelihood of quitting at 6 months as compared with other cancer patients suggesting that physician led cessation support may be more effective in patients with tobacco related cancers. However, data from a separate study suggest that enhanced tobacco cessation through increased provider education resulted in improved tobacco assessment and cessation support, but unchanged quit rates (18).
Effective tobacco cessation in cancer patients may involve several factors. Successful tobacco cessation is related to other comorbid conditions such as degree of nicotine dependence, alcohol use, and psychiatric disease in cancer patients (19–23). Self-blame and facilitation by family members has also been associated with the effectiveness of tobacco cessation in cancer patients (24–25). A recent study demonstrated that cancer stage, treatment, comorbidity, insurance, education, and emotional support were predictors for tobacco cessation in cancer patients (26). Successful tobacco cessation may require attention to demographic, comorbid, and cancer treatment related details; however, increasing active cessation support should be the first step for oncologists to promote cessation for cancer patients.
Active cessation support by physicians could involve direct intervention by the physician or referral to a dedicated tobacco cessation program. Our study demonstrates that only 33% of physicians agree or strongly agree that they “have had adequate training in tobacco cessation interventions” and 82% agree or strongly agree that “clinicians need more training in tobacco assessment and cessation interventions.” However, less than 50% report “lack of training or experience in tobacco cessation interventions” as a barrier to providing cessation interventions. Collectively, these data suggest that increased clinician education may improve confidence in providing cessation support, but may not address physician perceived barriers to cessation. As noted earlier, “inability to get patients to quit” and “patient resistance to treatment” were the dominant perceived barriers to providing tobacco cessation. Overall, these data suggest that additional efforts to improve tobacco cessation should incorporate a combination of improved physician education and improved tobacco cessation methods for cancer patients. Enhancing tobacco cessation in cancer patients further involves clearly defining tobacco use with standardized assessments, assessing prior and current tobacco use, assessing tobacco use during and following cancer care, and providing structured tobacco cessation support to cancer patients who smoke (27). In our study, low rates of cessation support in motivated practitioners supports the need for system level changes to support routine incorporation of tobacco assessment and cessation into standard cancer care. The need for these changes are supported by a recent survey of cancer centers demonstrating that approximately half define tobacco use effectively and most cancer centers do not provide well-defined tobacco use treatment services to cancer patients (28). In cancer patients, increasing the efficacy of tobacco cessation should also consider degree of addiction, motivation to quit, comorbid psychological distress or comorbidity, social support, and the potential stigma of a new tobacco related cancer diagnosis (29). Substantial research is required to develop better methods to enhance tobacco cessation support and efficacy in cancer patients.
In summary, these data show that thoracic oncology physicians recognize the importance of tobacco cessation as critical to cancer care, but many still do not routinely provide tobacco cessation assistance to cancer patients. Perceived inability to get patients to quit and lack of education for smoking cessation appear to be dominant barriers to providing cessation support. Despite these barriers, only 12% of respondents regard smoking cessation as a waste of time. Improving tobacco cessation will require assessing tobacco use and providing cessation support at diagnosis and during follow-up for cancer patients. Additional considerations to improve cessation support include increasing physician education, increasing the efficacy of tobacco cessation in cancer patients, and considering social support for cancer patients.
Supplementary Material
Acknowledgments
Sources of support: The distribution, collection, and financial support for this research effort were provided by IASLC. This work was supported in part by funding from the American Cancer Society (MRSG-11-031-01-CCE), the National Cancer Institute (CA 016056, CA 016672, and CA 097893), and the International Association for the Study of Lung Cancer (IASLC). The authors wish to acknowledge the efforts of Kristin Richeimer and the staff of the IASLC central office for assistance with administration and data management for the survey. The authors also wish to recognize the membership of IASLC without which the survey could not have been completed.
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