Despite decades of public awareness campaigns about the dangers of tobacco use, smoking continues to be the leading cause of preventable death in the United States, according to the U.S. Centers for Disease Control and Prevention. But researchers at The University of Texas MD Anderson Cancer Center have shown that an integrated program of counseling and proactive pharmacotherapy helps smokers overcome tobacco addiction. Now outreach initiatives are making similar programs available to high-risk populations and sharing smoking cessation tools and expertise with community physicians and other health care professionals.
Spurred by evidence that cancer patients who quit smoking during treatment have better survival outcomes than those who continue to smoke, MD Anderson faculty members established the Tobacco Treatment Program in 2006. The program is available at no charge to all MD Anderson cancer patients as well as employees and their families.
The program’s success has led to several ongoing clinical trials to further test its interventions and eventually disseminate the program to a broader population. Furthermore, the faculty and staff are using videoconference technology and specialized training courses to help community health care professionals establish similar smoking cessation programs.
Tobacco Treatment Program
MD Anderson’s Tobacco Treatment Program integrates behavioral counseling, pharmacotherapy, and—when needed—psychological or psychiatric care. The result is a program that is tailored to help each patient overcome the unique obstacles to quitting smoking that he or she faces. “We leave no stone unturned,” said Maher Karam-Hage, M.D., a professor in the Departments of Behavioral Science and Psychiatry and the associate medical director of the Tobacco Treatment Program. He added that although almost all participants in the program are cigarette smokers, the program also works for users of other tobacco products.
The first step in the program is an interview with a behavioral counselor who is a certified tobacco treatment specialist with training in motivational counseling. “The counselor explains to the patient what quitting involves, how to prepare, and what situations are likely to cause cravings,” said Vance Rabius, Ph.D., an instructor in the Department of Behavioral Science and the research director of the Tobacco Treatment Program. “The counselor works with the patient to develop strategies to deal with relapses, cravings, and withdrawal.”
A week or two before the patient plans to stop smoking, he or she begins pharmacotherapy. Typically, a combination of nicotine replacement therapies (e.g., patches with lozenges) or a combination of bupropion and nicotine replacement is used because such combinations are less expensive than varenicline and have equivalent success rates. However, pharmacotherapy may later be adjusted to fit the patient’s needs.
“We take a proactive approach to pharmacotherapy,” Dr. Karam-Hage said. “If the patient is not making progress or has trouble quitting, we change the medication from nicotine replacement to bupropion or varenicline and vice versa. We don’t wait for the treatment to fail.”
If the patient remains tobacco free after 3 months of pharmacotherapy, he or she receives another 3-month supply of bupropion or varenicline if one of those drugs was used. Dr. Karam-Hage believes the extended course of pharmacotherapy, which is longer than that prescribed by many physicians, improves the patient’s chances of long-term abstinence from smoking. If the patient does not remain tobacco free during the course of pharmacotherapy, the treatment team develops alternative cessation strategies and discusses these with the patient.
For the first 8–12 weeks, the patient meets with a behavioral counselor. All behavioral counseling sessions can be done in person, over the phone, or by videoconference. After the last of these sessions, the patient is followed up by phone every 3 months for a year.
Patients in the program also receive psychiatric evaluation and care if needed. “Psychological counseling and psychiatric treatment help deal with issues like other addictions, depression, or anxiety,” Dr. Rabius said. “The fact that we offer psychological and psychiatric treatment in addition to behavioral counseling—plus the way we approach pharmacotherapy—makes our program unique.”
The program also offers a phone-only option in which patients receive behavioral counseling but not pharmacotherapy or psychiatric care.
The results from the Tobacco Treatment Program’s 10-year experience were published last year. Among patients surveyed 9 months after their quit date, 47% reported that they had remained abstinent from smoking. “The success rate for smokers who try to quit on their own is about 3%,” said Dr. Karam-Hage, the first author of the report. “It’s not even comparable.”
Building on the success of the Tobacco Treatment Program, MD Anderson faculty members are working to give a broader population of smokers the tools they need to quit. The faculty members are also providing education and support to help physicians and other community health care providers implement smoking cessation programs.
The faculty members identified participants in MD Anderson’s low-dose computed tomography lung cancer screening program as a population that could benefit from smoking cessation intervention because the eligibility requirements for such screening include a smoking history of at least 30 pack-years (see House Call: Lung Cancer Screening, OncoLog, March 2017). For participants in the lung cancer screening program who are current smokers, a clinical trial of three smoking cessation strategies is now available (No. 2016-0626).
Participants in the trial are randomly assigned to one of three groups. Participants in the first group are referred to the State of Texas telephone quitline for counseling by a tobacco cessation counselor and receive nicotine replacement therapy in the form of a patch. Participants in the second group are referred to the state quitline and receive bupropion, varenicline, or nicotine replacement therapy as prescribed by the screening radiologists. Those in the third group are referred to the Tobacco Treatment Program. The trial, led by Paul Cinciripini, Ph.D., a professor in and chair of the Department of Behavioral Science, will compare 6-month smoking abstinence rates among the three groups. The researchers anticipate that the third group, which receives comprehensive treatment through the Tobacco Treatment Program, will have the highest quit rates.
Other clinical trials are bringing the Tobacco Treatment Program to new populations while evaluating the efficacy of the interventions used in the program. For example, two ongoing trials led by Dr. Cinciripini are comparing the efficacy of varenicline to that of nicotine replacement therapy in participants who also receive behavioral counseling. Both trials (Nos. 2014-0207 and 2014-0213) are currently enrolling smokers age 18–75 years.
Another population that could benefit from a smoking cessation program is patients treated at publicly funded local mental health authorities (LMAHs) for bipolar disorder, chronic depression, and psychotic disorders. “The smoking rate is 60%–70% in this population,” said Jan Blalock, Ph.D., an associate professor in the Department of Behavioral Science. “These patients are dying up to 25 years younger than people in the general population, predominantly from smoking-related illnesses.”
To help practitioners at LMAHs throughout Texas provide smoking cessation services, Dr. Blalock and her colleagues in MD Anderson’s EndTobacco initiative and Tobacco Treatment Program as well as at Rice University developed a videoconference format called Project TEACH (Tobacco Education And Cessation in the Health System). Project TEACH is an extension of Project ECHO (Extension for Community Healthcare Outcomes), a worldwide program in which specialists at academic medical centers share information and discuss cases with providers in underserved communities. Project TEACH began 2 years ago to provide telementoring for clinicians and counselors at LMAHs in Texas, and the program has recently been expanded to include community health care practitioners throughout the country.
Each Project TEACH videoconference connects 15–20 participants with a multidisciplinary team of MD Anderson experts. Part of each session is devoted to didactic information about evidence-based practices in pharmacotherapy or counseling for smoking cessation, and part is an interactive discussion about current cases. There is no cost to participants.
Also provided free of charge is an online course about pharmacological options and counseling to help patients quit smoking. The course is available to physicians, physician assistants, nurse practitioners, counseling clinicians, and other health care professionals for continuing education or continuing medical education (CME) credit.
MD Anderson also hosts an in-person course through which licensed professional counselors, social workers, and other professionals can become certified tobacco treatment specialists. The 4-day course, which is accredited by the Council of Tobacco Treatment Training Programs, is held 2 or 3 times each year. A registration fee is required.
Those who complete the tobacco treatment specialist certification course are encouraged to join the Project TEACH videoconferences. “Practitioners who want to provide good, evidence-based tobacco cessation services may benefit from intensive training followed by the opportunity to reinforce their knowledge and discuss cases with our experts and the other partners in the videoconferences,” Dr. Blalock said.
Dr. Rabius encourages physicians to use these resources and offer smoking cessation services to their patients who smoke. “At a minimum, doctors can refer their patients to a quitline and get them started on pharmacotherapy,” he said. “But I would advise community physicians to look into our CME and videoconference programs to improve their understanding of smoking cessation.”
For more information, contact Dr. Jan Blalock at 713-745-1728 or firstname.lastname@example.org, Dr. Maher Karam-Hage at 713-792-7113 or email@example.com, or Dr. Vance Rabius at 713-792-0919 or firstname.lastname@example.org.
Karam-Hage M, Oughli HA, Rabius V, et al. Tobacco cessation treatment pathways for patients with cancer: 10 years in the making. J Natl Compr Canc Netw. 2016;14:1469–1477.
Wippold R, Karam-Hage M, Blalock J, et al. Selection of optimal tobacco cessation medication treatment in cancer patients. Clin J Oncol Nurs. 2015;19: 170–175.
To Learn More...
To learn more about the ongoing clinical trials of smoking cessation interventions, visit www.clinicaltrials.org and search for trial No. 2016-0626, 2014-0213, or 2014-0207.
To learn more about Project TEACH, visit http://bit.ly/2xdESQk.
To learn more about the CME course on behavioral and pharmacological treatments for tobacco addiction, visit https://study.mdanderson.org, sign in, select “Courses,” click “Browse More Courses,” and choose “Provider Tobacco & Nicotine Counseling for Adults and Adolescents.”
OncoLog, November-December 2017, Volume 62, Issue 11-12