Tragic Triad of Tobacco Dependence, Cancer, and COVID-19 Pandemic: An Urgent Call for Attention by Health Care Systems and Professionals

Abstract

Tobacco smoke is a well-known carcinogen associated with multiple malignancies. Patients with cancer, as well as survivors, who continue to smoke are at a greater risk for poor cancer treatment outcomes. With the emergence of the COVID-19 pandemic, there is increased frequency and severity of the infection in patients with cancer. Furthermore, smoking and/or vaping increases incidence or likelihood of progression of COVID-19. Cigarette smoking, cancer, and COVID-19 each impose disproportionate burden of illness and death among racial and ethnic minorities. Geographic and population-specific analyses reveal that neighborhoods with lower income and higher minority populations have more tobacco/vape shops and face increased risk associated with tobacco marketing. Referral to tobacco cessation has been reduced during the pandemic. To reduce the adverse health effects of tobacco dependence among patients with cancer during the pandemic, urgent evidence-based solutions are described for health systems and professionals to prioritize tobacco cessation for patients with cancer in the midst of the COVID-19 pandemic, on the basis of cessation implementation at City of Hope Medical Center.

Introduction

In the article that accompanies this editorial, Burris et al¹ shows that among 26,365 patients with cancer, among the 21% current smokers universally referred for tobacco cessation, only 17% initiated cessation efforts. Importantly, the heightened deleterious effects of the triad of tobacco dependence, cancer, and COVID-19, especially in minorities, should stimulate the deployment of multilevel actions by health systems, clinicians, community health agencies, researchers, and policymakers. Therefore, this article offers a multi-system, and patient responsive approach to the challenge of tobacco cessation while also attending to the reality of the tragic triad of tobacco dependence, COVID-19 infection, and cancer.

Tobacco Dependence

Tobacco use is the single most prevalent cause of preventable disease, morbidity, and premature mortality.² Patients with cancer and survivors who continue to smoke cigarettes are at a greater risk for poor cancer treatment outcomes.² Health disparities are seen in cigarette smoking among ethnic minority groups. Like cigarette smoking and cancer, COVID-19 also imposes disproportionate burden of illness and death among racial and ethnic minorities.³ This population often has more limited access to health care, COVID-19 testing, tobacco cessation treatment, and a healthy physical environment, resulting in less success in attempting to quit.⁴

Both combustible cigarette smoking and vaping (including e-cigarettes or pods) are associated with increased risk of COVID-19 infection. COVID-19 infection was 2.3-fold higher in cigarette users, 5.0-fold higher in e-cigarette users, and 6.97-fold higher in dual users compared with nonsmokers. COVID-19 symptoms were also worse in recent dual users.⁵

Geographic and population-specific analyses revealed that neighborhoods with lower income and higher minority populations had a greater number of tobacco and vape shops.⁶ Hence, ethnic minority and lower-income communities face increased risk for excessive tobacco retailing and advertising. Studies revealed that minority patients with cancer, in particular African Americans, were at increased risk for COVID-19 infection and worse outcomes.⁷ The complex interplay between structural, biologic, social, economic, cultural, behavioral, and environmental determinant factors contribute to worse cancer outcomes than White adults.⁸

During the pandemic, the WHO urges banning tobacco and e-cigarettes in public places as a public health must.⁹ Some countries even adopted a national approach to banning or limiting the sale of tobacco products to mitigate the challenges to the health care system from COVID-19.^10,11 In the United States, the Food and Drug Administration delayed the review of vaping products submitted by 800 companies during the pandemic. Tobacco companies undermined tobacco control policy by introducing disposable pods, marketing with doorstep deliveries, and festive pandemic-themed discounts, and increasing new flavors to younger adults and teens.¹² Tobacco dependence is thus a growing risk during the pandemic and is a higher risk in African Americans and ethnic minority groups.

The COVID-19 Pandemic Reduced Quitline Referrals

Quitline counseling offers motivational benefits of social support and behavioral interventions,³ and as a safety net to the great majority of tobacco users statewide and nationwide, it has also been reported to sustain tobacco cessation for patients with cancer.¹³ Tobacco users' self-referral to the quitline decreased in March 2020 compared with March 2019.^14,15 Clinician referral to the 800-QUITNOW hotline for tobacco cessation also decreased during 2020 and 2021.¹⁶ Tobacco users reported higher postlockdown tobacco consumptions rates compared with prelockdown.¹⁷ In March 2021, with the reopening of the economy on the horizon, North American Quitline Consortium has reported a 9.7% increase in call volume from January 1 to March 31, 2021, compared with 2020 with increased direct referrals, e-referrals, and encouragements from providers.¹⁸

The COVID-19 Pandemic Caused Low Cancer Screenings and Diagnostic Delays

Cancer outcomes are dependent on early diagnosis. Cancer screening during the COVID-19 pandemic has been markedly decreased.^19,20 The proportion of patient with non–small-cell lung cancer diagnosed in late stages III-IV increased from 62.7% in 2019 to 74.7% during the pandemic.²¹ In patients with breast cancer, patients diagnosed during the pandemic less often had stage 0 (13.4%) compared with patients diagnosed in 2018 (26.2%), while more patients had stages II or III during the pandemic (28.6% compared with 21.3% prepandemic in 2018).²⁰

Cancer Outcomes Are Worse If Patients Continue to Smoke After Diagnosis

Patients with cancer who continue to smoke during their anticancer therapy have worse outcomes. The mortality of patients who continued to smoke after cancer diagnosis was 20% higher compared with patients who stopped smoking within the year before diagnosis.²² Patients with early-stage non–small-cell lung cancer who stopped smoking had a 5-year survival of 70% versus only 33% for smokers who continued to use tobacco.²³ It is therefore important to reduce smoking as an important component of a cancer treatment plan in current smokers.

COVID-19 Disease Is Worsened by Cancer and Tobacco Dependence

Patients who had cancer and COVID-19 had 26% mortality, compared with only 1.8% in Americans without cancer and not in nursing homes.²⁴ Moreover, patients with cancer had a higher risk of COVID-19 infection compared with patients without cancer, specifically with a relative risk of 7.14 for patients with a recently diagnosed cancer. Among patients with COVID-19, outcomes were worse in patients with cancer compared with those without cancer: need for hospitalization was 47.5% compared with 24.3%, and mortality was 14.9% versus 5.3%, respectively.²⁵

The sequelae of COVID-19 infection are also worsened by smoking. Patients with cancer diagnosed with COVID-19 were more likely to have a history of smoking.²⁶ Mortality from COVID-19 was 1.8-fold higher in smokers compared with nonsmokers.²⁷ In another study, active smoking was also considered a predictor of 28-day mortality among critically ill patients with COVID-19.²⁸ In a systematic review, current smokers were twice as likely to develop severe symptoms from COVID-19 compared with nonsmokers, and patients with compromised pulmonary status upon admission had worse outcomes.²⁹ Also, patients with COVID-19 and a history of tobacco use experienced a much higher risk of developing progression of pneumonia in the setting of COVID-19.³⁰ A meta-analysis of patients in the United States, Korea, and China found that smoking was significantly associated with COVID-19 progression.³¹ Studies also revealed that patients with COVID-19 who smoke had an adverse disease prognosis.³⁰ Current history of smoking is significantly associated with risk of severe COVID-19 disease,³² whereas current or past smoking history was associated with increased need for mechanical ventilation usage.³³ COVID-19 infection can be even more detrimental when combined with pre-existing lung damage because of smoking.³⁴ In addition, patients with cancer who smoke and who are an ethnic minority and lower income are more vulnerable to poor outcomes from COVID-19.¹⁶

The COVID-19 Pandemic Is a Trigger to Tobacco Use

The use of nicotine products, including smoking, is often triggered by distress (eg, depression, stress, job loss, family illness, caregiver burnout, loss of loved ones, boredom, and social isolation).³⁵ The COVID-19 pandemic increases all the above triggers to use.

The California Smokers' Helpline utilization decreased in March 2020 compared with March 2019.¹⁵ Interestingly, although tobacco cessation efforts decreased in the United States during the pandemic, the United Kingdom had a different experience. More than 1 million people quit smoking during the pandemic,³⁶ indicating that public health initiatives may reduce the deleterious impact of tobacco use on cancer and COVID-19. With the assistance of physicians and health care systems, this may be a teachable moment to which tobacco users will respond.

The City of Hope Model for Tobacco Control and Tobacco Cessation During the Pandemic

On the basis of the extensive evidence above, effective ways to address the tragic triad of smoking and its effect on patients with or at risk for cancer and COVID-19 infection and outcomes are essential. The City of Hope used implementation science and evidence-based strategies to develop and implement a program for enhanced tobacco control.³⁷

A Call to Action: Recommendations for Health Systems and Professionals to Prioritize Tobacco Cessation for Patients With Cancer Amid COVID-19

The deleterious effects of the triad of tobacco dependence, cancer, and COVID-19, especially in minorities, should mandate consideration of multilevel evidence-based actions by health systems, clinicians, community health agencies, and governments. The details of the strategies we used over the first 6 months of 2021 at the City of Hope are described in Table 1.

TABLE 1.

Recommendations for Mitigation of the Tragic Triad of Tobacco Dependence, Cancer, and COVID-19 Evidenced by Components of the City of Hope Model

The results from January 1, 2021, to June 30, 2021, of implementing these strategies at City of Hope are listed in Table 2. These results compare our academic center at Duarte, CA, where the tobacco use prevalence is relatively low 4.0%, with one of our network community sites with the highest smoking prevalence 9.4% at Antelope Valley, CA. Tobacco cessation at Duarte continuously used certified tobacco treatment specialists (TTS) and named multilevel clinician and nurse tobacco cessation champions, whereas a TTS and champions were only implemented later at Antelope Valley at the end of month 4; so, the Antelope Valley represents results that lack the full support of champions and a TTS. The tobacco use populations differed slightly. Although minorities constituted 38.8% of smokers at Duarte, a similar rate of minority smokers was seen at Antelope Valley, 38.9%. However, more Asian smokers proportionally were seen at Duarte, 8.9%, compared with 1.4% at Antelope Valley (P < .0001), whereas Black/African American smokers were 8.2% at Duarte but 22% at Antelope Valley (P < .0001). More frequent engagement of smokers in the tobacco treatment program in Duarte (90.6%) compared with Antelope Valley (13.1%) and greater rate of prescribing cessation medications (30.3% v 10.5%) indicate the evidence-based benefits of using multilevel champions promoting cessation and the use of TTS personnel to engage smokers including minorities in tobacco cessation. Although we did not have patient use data to evaluate how often patients actually took the prescribed medications, they were more often prescribed at the academic center in Duarte compared with the community site in Antelope Valley. We are currently tracking the use of champions and TTS in Antelope Valley over the next evaluation period (6 months) to determine whether consistent availability of champions and TTS will increase medication prescription and engagement of patients in the tobacco control program with ultimate increase in long-term success in cessation for patients who use tobacco products.

TABLE 2.

Evidence-Based Results of the City of Hope Tobacco Control Program at the Academic Tertiary Care Referral Center in Duarte, CA, and in the Community Cancer Care Center in Antelope Valley, CA

During implementation, patients identified as tobacco users received education via hard copy tobacco control brochures or brochures available on the online patient portal, and were offered access to national, state, and county quitlines, as well as either telehealth phone or video tobacco cessation counseling, or face-to-face in-person counseling, which was comparable in Duarte (30.5%) versus Antelope Valley (31.5%). Importantly, of engaged patient smokers who were evaluated at 6 months, abstinence was not significantly different at Duarte (27.2%) compared with Antelope Valley (22.5%), indicating that the use of a structured tobacco treatment program such as that at City of Hope involving champions, TTS personnel, and telehealth services can produce similar effectiveness results in academic centers and in community sites, and help mitigate the tragic triad across the clinical spectrum.

As City of Hope continues the system-wide implementation of the tobacco control program and collects additional mature data, the results will be updated in future publications to refine these initial observations of this publication on the basis of the first 6 months of follow-up. These will further extend the conclusions about the reach and effectiveness of these interventions.

Consideration of each of these evidence-based strategies is important to improve the outcomes and reduce the health risks among cancer patients who smoke. Essential components of this multi-system approach includes: broadening insurance coverage for tobacco cessation including medications for cancer patients who smoke; expanding public, patient, and clinician education; adopting and continuously promoting strong position statements for tobacco cessation especially among clinicians and institutional leaders; prioritizing cessation services by cancer centers and clinics as recommended by the National Cancer Institute (NCI) Cancer Moonshot C3I (Cancer Center Cessation Initiative) program; expanding telehealth and navigation; returning to guideline-compliant cancer screening and treatment; reducing health disparities by attending to societal and patient level risks; preparing patients for relapse and providing prompt interventions; and promoting COVID-19 and other vaccinations of patients with cancer, especially tobacco users and vulnerable patients.

In conclusion, the deadly intersection of tobacco dependency, cancer, and COVID-19 represents a tragic triad of diseases with significant racial disparities. Cancer centers and health care providers play critical roles to eliminate tobacco use, protect public health, reduce health disparities, and advance health equity using evidence-based solutions. The health care industry must move quickly by partnering, collaborating, and being engaged with other community-based and advocacy organizations in the new post–COVID-19 era.

AUTHOR CONTRIBUTIONS

Conception and design: Cary A. Presant, Jonjon Macalintal, Kimlin Tam Ashing, Sophia Yeung, Howard West

Administrative support: Cary A. Presant, Jonjon Macalintal, Amartej Merla

Provision of study materials or patients: Brian Tiep

Collection and assembly of data: Cary A. Presant, Jonjon Macalintal, Sophia Yeung, Brian Tiep, Amartej Merla

Data analysis and interpretation: Cary A. Presant, Jonjon Macalintal, Howard West, Amartej Merla, Tanyanika Phillips

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Tragic Triad of Tobacco Dependence, Cancer, and COVID-19 Pandemic: An Urgent Call for Attention by Health Care Systems and Professionals

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/op/authors/author-center.

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