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Helping patients to reduce tobacco consumption in oncology: a narrative review

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Abstract

The present overview focuses on evidence of smoking cessation approaches in oncology settings with the aim to provide health personnel a critical perspective on how to help their patients. This narrative review is structured in two main sections: the first one describes the psycho-cognitive variables involved in the decision to continue smoking after a cancer diagnosis and during the treatment; the second section relates methods and tools may be recommended, being evidence-based, to support smoking cessation in oncology settings. Active smoking increases not only susceptibility to common cancers in the general population, but also increases disease severity and comorbidities in cancer patients. Nowadays, scientific evidence has identified many strategies to give up smoking, but a lack of knowledge exists for treatment of nicotine dependence in the cancer population. Health personnel is often ambiguous when approaching the problem, while their contribution is essential in guiding patients towards healthier choices. We argue that smoking treatments for cancer patients deserve more attention and that clinical features, individual characteristics and needs of the patient should be assessed in order to increase the attempts success rate. Health personnel that daily work and interact with cancer patients and their caregivers have a fundamental role in the promotion of the health changing. For this reason, it is important that they have adequate knowledge and resources in order to support cancer patients to stop tobacco cigarette smoking and promoting and healthier lifestyle.
Lucchiari et al. SpringerPlus (2016) 5:1136
DOI 10.1186/s40064-016-2798-9
REVIEW
Helping patients toreduce tobacco
consumption inoncology: a narrative review
Claudio Lucchiari1*, Marianna Masiero2,3, Andrea Botturi4 and Gabriella Pravettoni2,3
Abstract
The present overview focuses on evidence of smoking cessation approaches in oncology settings with the aim to
provide health personnel a critical perspective on how to help their patients. This narrative review is structured in two
main sections: the first one describes the psycho-cognitive variables involved in the decision to continue smoking
after a cancer diagnosis and during the treatment; the second section relates methods and tools may be recom-
mended, being evidence-based, to support smoking cessation in oncology settings. Active smoking increases not
only susceptibility to common cancers in the general population, but also increases disease severity and comor-
bidities in cancer patients. Nowadays, scientific evidence has identified many strategies to give up smoking, but a
lack of knowledge exists for treatment of nicotine dependence in the cancer population. Health personnel is often
ambiguous when approaching the problem, while their contribution is essential in guiding patients towards healthier
choices. We argue that smoking treatments for cancer patients deserve more attention and that clinical features,
individual characteristics and needs of the patient should be assessed in order to increase the attempts success rate.
Health personnel that daily work and interact with cancer patients and their caregivers have a fundamental role in the
promotion of the health changing. For this reason, it is important that they have adequate knowledge and resources
in order to support cancer patients to stop tobacco cigarette smoking and promoting and healthier lifestyle.
Keywords: Oncology, Cigarette smoking, Smoking cessation, Decision-making
© 2016 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made.
Background
Tobacco cigarette smoking is the leading cause of pre-
ventable death in the world. In 2011 the World Health
Organization (WHO) declared that smoking caused six
million deaths annually, and in 2030 it will kill eight mil-
lion people each year (WHO 2011).
Bio-physiological evidence suggests that smoking is the
main cause of respiratory diseases (e.g. chronic obstruc-
tive pulmonary disease and pulmonary emphysema),
cardiovascular events (e.g. aneurysm and stroke) and
many cancers (esophagus, larynx, oral cavity, bladder,
stomach, kidney, squamous cell carcinoma of the cervix;
Ehlers and Bronars 2012). Statistical figures confirm that
tobacco dependence causes 30% of all cancers and 80%
of deaths from neck, head, and lung cancer (Morgan etal.
2011). Particularly, about 90% of lung cancer is assign-
able to tobacco cigarette smoking (Nayan etal. 2011).
Despite this evidence, many patients still smoke regu-
larly after a diagnosis of cancer. In 2013 the American
National Cancer Institute published a scientific state-
ment on treating tobacco dependence in the cancer pop-
ulation. e report highlighted that 50% of individuals
with cancer who smoke before diagnosis continue smok-
ing during treatment, and that, for patients who gave up
smoking, the relapse rate was very high (Toll etal. 2013).
Data showed that 23–35 % of head and neck cancer
patients, and 13–20% of lung cancer patients who were
smoking before their diagnosis, continued to smoke after
the diagnosis and during treatment itself (Nayan et al.
2011), while de Bruin-Visser etal. (2012) reported that
35–72% of head and neck cancer patients’ smoke despite
the diagnosis.
Also women with breast cancer are reported as con-
tinuing to smoke after the diagnosis (Land etal. 2011). In
Open Access
*Correspondence: claudio.lucchiari@unimi.it
1 Department of Philosophy, Università degli Studi di Milano, Milan, Italy
Full list of author information is available at the end of the article
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Lucchiari et al. SpringerPlus (2016) 5:1136
this study, cigarette smoking was found to be negatively
correlated to treatment adherence.
Continuing to smoke after a cancer diagnosis may
produce several adverse health outcomes (Cropley etal.
2008). Epidemiological research shows that tobacco
cigarette smoking decreases survival time (Gritz and
Demark-Wahnefried 2009), it increases the risk of second
primary malignancies (Zevallos etal. 2009) and the like-
lihood of recurrences (Schnoll etal. 2004). For instance,
smokers with Hodgkin’s disease have an increased risk
of a second primary lung cancer (McBride and Ostroff
2003) when compared to never-smokers under the same
conditions. Also, it has been shown that tobacco use
decreases survival rate after hematopoietic stem cell
transplantation (Marks et al. 2009; Ehlers etal. 2011).
Furthermore, cigarette smoking decreases treatment effi-
cacy (Waller etal. 2010) and increases complications and
side-effects (Schnoll etal. 2004) for many types of cancer.
In this regard, clinical studies revealed that in head and
neck (Blalock etal. 2011), and lung (Zhang etal. 2009)
cancer patients, smoking behavior decreases the efficacy
of radiotherapy, while increasing drug toxicity and side-
effects (such as impaired pulmonary function, nausea,
and dry mouth) (Nayan etal. 2011). Daniel etal. (2009)
showed that patients with lung cancer who did not dis-
continue smoking reported more pain during the disease
progression than former smokers and non-smokers. Sim-
ilar concerns have also been observed in patients with
bladder and renal cancer (Videtic et al. 2003). Finally,
smoker patients have a high risk of developing postop-
erative complications than do non-smoker patients, for
example showing poor wound healing (omsen et al.
2010a, b; see Table1).
In spite of the evidence, there is still a significant lack
of smoking treatment research for oncology patients. A
cancer diagnosis may provide a useful teachable moment
(Gritz 1991) for quitting smoking, but this chance is fre-
quently undervalued by the healthcare system (Weaver
etal. 2012).
A number of studies reported that oncology patients
actually try to give up, but they generally make their
attempts without help. For example, a recent study by
Vaidya etal. (2014) reported that many patients keep
on smoking even after a diagnosis of lung cancer. Khul-
lar et al. (2013) stated that patients do not receive
enough support from physicians. Indeed, 50% of phy-
sicians do not regularly talk about antismoking strate-
gies with patients. Cooley etal. (2009) have shown that
despite the a broad diffusion of information about the
benefits of smoking cessation after a lung cancer diag-
nosis, few patients actually succeed in their attempt and
find little support from health personnel pre- and post-
surgery. Confirming this evidence, a large online survey
conducted by Warren etal. (2013) in 1507 members of
the International Association for the Study of Lung Can-
cer revealed that though most physicians believes smok-
ing cessation to be an important issues for their patients,
only 40% discuss quit options and only 39% actively sup-
port patients.
Generally, oncologists provide wide-ranging sugges-
tions regarding smoking-related risks, but they do not
give detailed information regarding available treatments,
nor do they offer a support program during the whole
therapeutic journey (Weaver etal. 2012). is view has
been recently supported by a qualitative study conducted
by Champassak et al. (2014), which showed, through a
series of interview, the mismatch between the physicians’
believe of the importance of smoking cessation programs
and the actual behavior during visits. Indeed, physi-
cians report a lack of confidence in their smoking cessa-
tion counseling ability. Furthermore, physicians rarely
reported to use recommended strategies, even when
they are acknowledged. Another particular case is that of
hematologic cancers. Indeed, in a hematological oncol-
ogy department for patients undergoing hematopoietic
stem cell transplantation, quitting is a priority, since
studies exist (Chang etal. 2004) associating smoking with
worse outcomes. Despite this, Ehlers etal. (2011) showed
Table 1 Summary ofthe benets related tosmoking ces-
sation duringand aftercancer treatment
Benets ofsmoking cessation post-diagnosis
Physical dimension
Decreasing the side-effects of the therapy
Increasing treatment efficacy
Overcoming chemo resistance
Improving outcome of the surgery
Counteracting tumor progression
Reducing fatigue
Increasing activity level
Reducing the likelihood of developing second primary malignancies
Avoiding recurrence
Improving survival rate
Psychological dimension
Improving cognitive process
Enhancing psychological well-being
Increasing self-esteem
Reducing blame (when cancer is smoking-related)
Supporting self-efficacy health behavior-related
Improving mood
Health behaviors
Supporting healthy lifestyle
Promoting preventive behavior
Enhancing general quality of life of the patients (e.g. quality of sleep)
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Lucchiari et al. SpringerPlus (2016) 5:1136
that many hematologic patients continue to smoke after
diagnosis. Also, authors noted the lack of studies address-
ing the issue of helping patients quit smoking (Ehlers and
Bronars 2012), and the training of healthcare profession-
als in the management of the smoker patient.
Starting from this theoretical background, the main
aim of this brief review is to sketch an overview of the
available options to approach smoking dependence in an
oncology setting. In order to achieve this goal, the paper
has been structured into three conceptual sections. e
first section describes the role of the psycho-cognitive
processes that reinforce cigarette smoking behavior in
patients with cancer. e second section discusses the
cognitive-behavioral interventions and smoking cessa-
tion aids, focusing both on advantages and disadvan-
tages, in in-patient and out-patient settings. Finally, we
offer some suggestions for health professionals to over-
come roadblocks and to improve the smoking cessation
success rate in cancer patients.
Method
is narrative review is structured in two main sec-
tions: the first one describes the psycho-cognitive vari-
ables involved in the decision to continue smoking after
a cancer diagnosis and during the treatment; the second
section relates methods and tools may be recommended,
being evidence-based, to support smoking cessation in
oncology settings.
Searches were conducted through MEDLINE,
EMBASE, PubMed, SCOPUS, PsycINFO and Google
Scholar. e following keywords or combinations were
used: cigarettes smoking, cancer, oncology patient,
oncology setting, smoking cessation, antismoking treat-
ment, nicotine dependence, nicotine replace treatment,
varenicline, bupropion, electronic cigarettes, smoking
cessation counseling.
In the first section, we considered papers from 1990 to
May 2016, using previous systematic reviews, national
and international reports, and empirical studies. While
in the second section, we included only controlled trials
studies from 1990 to May 2016.
Articles in languages other than English and letters
and editorials were excluded. e initial search identi-
fied 763 articles. An initial review of the titles abstracts
of these articles by 2 of the authors identified 133 articles
that were potentially relevant to the current review. e
abstracts of these articles were then evaluated against the
inclusion criteria by the authors, resulting in 35 articles
being identified as eligible for inclusion, with an addi-
tional 6 articles identified during manuscript preparation,
for a total of 41 articles. is review provides a narrative
synthesis of the findings from previous key reviews and
empirical studies identified in the literature search.
Inclusion and exclusion criteria section1:
We included article assessing the behavioral, psychologi-
cal and cognitive characteristic of adult smokers after a
diagnosis of cancer, including nicotine dependence level
and motivation to quit. We also reviewed paper (review
or empirical studies) that evaluated the rate of patients
that continue smoking after a cancer diagnosis. We
excluded editorial, opinion papers, letters and articles
related to adult smokers after childhood cancer.
Inclusion and exclusion criteria for section2:
We included prospective controlled studies about adults
patients after a diagnosis of cancer during their clinical
treatment, measuring the effectiveness of a smoking ces-
sation treatment on smokers who received a diagnosis of
cancer and describing the smoking cessation methods
used, including the type of provider and the clinical set-
ting. We considered studies that specify the cancer sites
of patients and stage. We excluded studies on mixed pop-
ulation (cancer patients and other diseases), cohort stud-
ies as well as surveys.
Cognitive prole ofthe cancer patient who smokes
Westmaas et al. (2015), in a large prospective study
on a US cohort (including more than 12,000 smokers)
showed that a cancer diagnosis is associated with sig-
nificantly higher rates of quitting smoking within both 2
and 4years of the diagnosis. Almost one in three smokers
who received a cancer diagnosis in their study had quit
smoking within 2years, compared with fewer than one in
five smokers who had never received a cancer diagnosis.
Moreover, the greater quitting rate among cancer-diag-
nosed smokers is maintained at 4years. Interestingly, also
non-smoking related diagnosis affected patients’ smoking
habits. However, even though a diagnosis of cancer seem
to be a true teachable moment, not all patients actually
change their behavior. In particular, patients with preex-
isting chronic conditions that are linked to smoking (e.g.
chronic obstructive pulmonary disease) have low rates of
quitting after cancer diagnosis. Coherently, Burris etal.
(2015) aggregating data across 131 studies on head and
neck cancer patients, found that about 50% of smokers
patients continue smoking after diagnosis, while previous
studies reported a range of 35–72% (Ostroff etal. 2013).
ese data may help in describing the typical cancer
patient who continue smoking after the diagnosis. Duffy
et al. (2012) describe this patient as a heavy smoker
(with a mean consumption of 28 cigarettes per day for
35–40years) with a high level of nicotine addiction with
a history of failed quitting attempts and some smoking-
related pathological condition. Even when these patients
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Lucchiari et al. SpringerPlus (2016) 5:1136
decide to attempt to stop smoking, the success rate is
generally low. For instance, Walker etal. (2006) showed
that lung cancer patients start smoking again only
2months after the surgery, supporting the idea that this
population is particularly challenging for smoking cessa-
tion specialists (Park etal. 2011).
Since, heavy smoking (smoking more than 20 cigarettes
a day, even though different definitions are present in lit-
erature; Husten 2009) and smoking related diseases are
particularly associated with lung and oral cavity cancer
(Gandini etal. 2008), we may expect to find more patients
who continue smoking after diagnosis in these pathologi-
cal conditions. Actually, several studies of non–small-cell
lung cancer patients have shown that many patients con-
tinue smoking (Gritz 1991; Dresler etal. 1996; Sanderson-
Cox etal. 2002) with estimates ranging from 13 to 70%.
In particular, Walker et al. (2004) in a retrospective
study of 49 lung cancer patients reported that patients
who were younger and less educated were more likely to
return to smoking after surgery. ey also found a cor-
relation of relapse with depression and social support.
Authors suggested that patients stop smoking imme-
diately before and after surgery, but relapse to smoking
remains a problem.
Cooley et al. (2009) in a study on a sample of 94
patients with early stage non-small cells lung cancer
reported similar results, but they also found a correlation
between smoking and pain. Authors collected data at 1, 2
and 4months after surgery and their results suggest that
the presence of pain is significantly correlated with smok-
ing after surgery.
Schnoll et al. (2005) among 109 lung and head and
neck cancer patients, showed that continued smoking
after 3months post-surgery is associated to low quitting
motivation and smoking-related beliefs that increase the
perception of disadvantages of quitting. In fact, in their
study authors found that patients who continue smoking
believe that cons of quitting are more than pros. False or
biased smoking-related beliefs are frequently present in
smokers. Different studies reported that smokers usually
show some kind of belief bias, ranging between 20 and
80% (Masiero etal. 2015). is is also true in oncology
settings. Such biased thoughts and beliefs may be exem-
plified by patients developing the idea that the cancer
does not relate to individual choices and behavior but
only to uncontrollable factors such as genetic predisposi-
tion, environmental pollution, etc. (Arnett 2000).
In particular, smokers tend to underestimate smoking-
related risks (Borrelli etal. 2010). For instance, a study of
Bock etal. (2001), reported that 47.6% of smokers admit-
ted to the emergency department for acute respiratory
care did not believe that they had a condition that was
caused or made worse by smoking.
Furthermore, smokers compared with non-smokers
tend to underestimate risks concerning themselves, but
they often change their judgment when thinking about
others’ risks. is attitude is defined optimistic bias
(Weinstein etal. 2005; Weinstein 1989). It drives people
to believe that they are protected from the consequences
of potential sources of risk and reinforces cigarette smok-
ing. However, some authors (e.g. Milbury et al. 2012;
Gritz etal. 2005) have suggested that giving up smoking
may be facilitated if patients become aware of the possi-
bility of changing their behavior and in so doing reduce
further risks.
Cancer-related emotional distress may favor smoking
as well. Indeed, depression is often present in patients,
ranging between 3 and 31% (Krebber etal. 2014). Also
blame contribute to exacerbating patients’ psychologi-
cal distress. Paradoxically, this reaction seems to initiate
a vicious circle, which reduces the motivation to start an
antismoking program (e.g. Chapple etal. 2004). A study
by Shin etal. (2014) on 45 patients and 173 family mem-
bers who continued to smoke for at least 1 month after
the diagnoses reported interesting data about the emo-
tional experience of patients and their relatives. In this
study, most smoker patients report to experience guilt
toward their family (75.6%) and to conceal their smok-
ing behavior. Similarly, relatives who continue smoking
feel guilt toward patients (63.6%). Hence, both relatives
and patients experience negative emotions and try to
prevent conflicts hiding their behavior also to the health
personnel.
Long-term abstinence can be hindered by a negative
mood, since a correlation between cigarette smoking
and depression is well established (McClave etal. 2009).
Depressed smokers or smokers with a previous history
of major depression generally have a high level of nico-
tine dependence and a low probability of a successfully
attempt to stop smoking.
In oncology settings, depression is a critical issue for
patient management. Indeed, cancer patients can expe-
rience high levels of worries, fears, anxiety and nega-
tive emotions related to the disease and its treatment
(surgery, chemotherapy or radiotherapy, periodic clini-
cal meetings, long periods of hospitalization, tests and
examinations). Patients may then use cigarette smoking
as a coping strategy. Furthermore, the pharmacologi-
cal properties of nicotine, with its cognitive-enhancing
effects, reinforces the perceived valued of cigarettes since
they may be used to alleviate treatment-related negative
effects on memory and attention.
Spek etal. (2013) found that the decrease of self-effi-
cacy tends to negatively affect smokers’ confidence in
their ability to quit smoking. Actually, patients with
a high degree of confidence in their power to give up
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Lucchiari et al. SpringerPlus (2016) 5:1136
smoking have a higher success rate than smokers with
a low confidence. Also, they report less relapses after
an attempt to quit (McBride and Ostroff 2003; Elfeddali
etal. 2012).
Other context-related variables influence smoking ces-
sation, such as living or working with people who habitu-
ally smoke. Indeed, patients who live with smokers are
more likely to maintain their habit than are patients who
live with non-smokers or in a smoke-free home. Fur-
thermore, social and family support (relatives, friends,
colleagues and so on) can be an important factor in pro-
moting smoking cessation even though different stud-
ies have shown divergent results (Park etal. 2004). May
and West (2000) in a review of the literature found that
social support may be beneficial in helping smokers quit-
ting, even if more research is needed to clarify the role
of relatives, especially in cancer survivors. However,
Schnoll etal. (2002) in a study of 74 patients found that a
low readiness to quit smoking after a cancer was strongly
associated with the fact of having a relative at home who
smoke. After hospitalization, when the patient goes back
home, smoking-related cues (e.g. a habitual smoking
place; smoking-related daily routine; other people who
smoke; sensorial stimuli and the like) may influence their
ability to remain abstinent.
is fact has been considered as a serious barrier in
helping patients to stop smoking. Indeed, daily exposure
to smoking-related stimuli may produce physiological
and cognitive changes that favor urgency and craving
due to a so-called attentional bias. is cognitive bias
is related to the selective properties of the attention. It
concerns the attitude of smokers and former smokers to
orient their attention to tobacco cigarette smoking cues
(Field etal. 2009) favoring the need to smoke. Finally, Ark
etal. (1997) found that in head and neck cancer patients
heavy alcohol use is a negative predictor of smoking
cessation.
Smoking cessation interventions forcancer patients: state
ofthe art
Smoking interventions may be classified into two main
approaches: smoking cessation aids (SCAs) and cogni-
tive behavioral interventions (CBIs). Both methods are
used to approach cigarette addiction in healthy adults
and in cancer patients and they can be used alone or in
combination. However, most research on smoking cessa-
tion has been carried out on healthy people, while there
are only a few studies available on cancer patients and on
survivors (Duffy etal. 2012; see Table2).
Smoking cessation aids: SCAs
Smoking cessation aids involve three categories of ant-
ismoking strategies: nicotine replacement treatments
(NRTs), tobacco free cigarettes—(TFC) and medications
(mainly bupropion and varenicline).
Nicotine replacement treatment is very popular among
smokers. Generally, a first spontaneous attempt to give
up involves NRT (where available without a medical pre-
scription). ey provide nicotine, stabilizing its level in
the blood in order to avoid a withdrawal syndrome after
having stopped smoking. ey are available in different
forms including transdermal nicotine replacement prod-
ucts, patch, gum, lozenge, inhaler, spray and sublingual
tablets. Commonly, the treatment lasts for 10–12weeks,
but it is often prolonged to 6months. e type of NRTs
chosen depends on personal preference, but clinical con-
siderations should be issued too.
Two NRT groups, depending on the administration
method, are usually described. e first group includes
NRTs that require daily administration, generally based
on the use of patches. e second group include proto-
cols based on multiple administrations a day, so-called
short-acting NRT (Nides 2008).
e main aims of NRT are three: craving reduction,
withdrawal control and abstinence promotion (Stead
et al. 2008). A growing body of scientific literature
stresses that NRT helps patients to give up smoking
(Fiore etal. 2000). Pharmacological trials in particular
have shown that the combination of multiple forms of
NRT improves the interruption success rate (Ferguson
etal. 2011) also in medical settings (Hurt etal. 2009).
Also, NRTs have few side effects, being the most preva-
lent a transient nausea (Fiore etal. 2008). eir prin-
cipal weak point is the low compliance, since after a
short period many people interrupt the smoking cessa-
tion program, believing that they are able to control the
situation without further help (Balmford etal. 2011).
NRT may be successfully used with cancer patients,
generally in association with some form of counseling
and/or other pharmacological treatment (see Table2).
For instance, a retrospective study by Garces et al.
(2004) showed that a combination of NRT and other
behavioral and pharmacological treatment is as effec-
tive in head and neck cancer patients as in the general
population.
A particular type of NRT involves tobacco-free ciga-
rettes (TFCs) also called e-cigarettes. ese devices have
rapidly become widespread over the last 5years, and are
often used by smokers to reduce the daily number of cig-
arettes, or to smoke in places where tobacco cigarettes
are not allowed.
A TFC device is composed of a battery-powered device
that produces a vapour for inhalation. e steam contains
humectants, flavours, and pure nicotine. Liquids used in
e-cigarettes do not contain tobacco and do not require
combustion. ey may or may not contain nicotine.
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Lucchiari et al. SpringerPlus (2016) 5:1136
Table 2 Clinical trials onsmoking cessation from2000 to2014
CLINICAL TRIALS 2000–2014
Year Authors Design study Aim Sample Smoking cessation
intervention Follow-up Disease Outcome
1993 Gritz et al. Randomized controlled
study Assessing a provider-deliv-
ered smoking cessation
counseling program in
cancer patients
186 Group 1: usual care
including informa-
tion on the risks of
continued smoking and
benefits of cessation
and physician advice
to quit
Group 2: usual care advice
plus discussion of the
person’s readiness to
quit, provision of infor-
mational booklets, and
the physician’s expres-
sions of confidence in
the patient’s ability to
quit (plus booster ses-
sions during six monthly
appointments)
12 months Head and neck
cancers 60 % patients was absti-
nent (confirmed by
cotinine) and among
the remaining smokers,
consumption dropped
by 50 % (12/cigarettes/
day). No differences
between groups.
39 % of the sample
was not assessed at
12 month due to health
conditions, death and
dropout
1994 Stanislaw, Wewers Randomized controlled
study To examine the effect of
a structured smoking
cessation intervention
during hospitalization
on short-term smok-
ing abstinence
26 Structured counseling
smoking cessation
treatment during hos-
pitalization followed
by five weekly phone
calls after discharge
6 weeks (first post discharge
visit) Mix cancer sites abstinence rates con-
firmed by cotinine were
75 % for the interven-
tion and 40 % for usual
care
1998 Griebel, Wewers, Baker Prospective, two-group,
randomized clinical
trial
Assessing the effective-
ness of a nurse-
managed minimal
smoking-cessation
intervention among
hospitalized patients
with cancer
28 During hospitaliza-
tion, subjects were
assigned to a minimal
counseling smoking-
cessation intervention
group (n = 14) or to
usual care treatment
(n = 14)
6 weeks post intervention Mix cancer sites 21 % and 14 % of the
intervention and usual
care group, respectively,
were abstinent at
6 weeks
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Lucchiari et al. SpringerPlus (2016) 5:1136
Table 2 continued
CLINICAL TRIALS 2000–2014
Year Authors Design study Aim Sample Smoking cessation
intervention Follow-up Disease Outcome
2003 Schnoll et al. Randomized controlled
trial Assessing physician-
based smoking inter-
vention comparing to
usual care
432 Control Group (N = 218)
Usual care: minimal
advice. Intervention
Group (N = 217)
Intervention: quit-
ting advice; nicotine
replacement therapy;
self-help smoking
cessation guide;
telephone number for
additional assistance
and/or referral to a
cessation program;
assessed cessation
progress during sub-
sequent medical visits
6 months–12 months Breast, prostate, or
testicular cancer
or lymphoma
No association found
between physician-
based smoking inter-
vention and long-term
(6 months follow up
and 12 months follow
up) quit rates
2004 Wakefield et al. Randomized controlled
trial Evaluating whether
motivational inter-
viewing intervention
increases quit rates
137 Control Group (N = 63):
minimal advice.
Intervention Group
(N = 74): motivational
interviewing interven-
tion (over at 3-months
period); nicotine
replacement therapy
(in patients who
smoked more than
15 cigarettes per day),
family advice to quit,
and an in-person or
telephone follow-up
conversation. Follow-
up at 6-months
6 months Mixed cancer sites No evidence to support
efficacy of the moti-
vational interviewing
intervention
2005 Croghan et al. Method no stated Assessing individual
counseling interven-
tion comparing to
physician advice alone
30 Control Group (N = 11):
minimal advice.
Intervention Group
(N = 19): individual
counseling inter-
vention (1 session
for 45 min) plus
individualized nicotine
replacementtherapy
No information available Lung or Esopha-
geal cancer No evidence to sup-
port efficacy of the
individual counseling
intervention
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Lucchiari et al. SpringerPlus (2016) 5:1136
Table 2 continued
CLINICAL TRIALS 2000–2014
Year Authors Design study Aim Sample Smoking cessation
intervention Follow-up Disease Outcome
2005 Schnoll et al. Randomized controlled
trial Assessing cognitive-
behavioral therapy
plus Nicotine Replace-
mentTherapy (CBT)
comparing to General
Health Education
(GHE)
109 No indication about
dimension of control
and experimental
group. Control group:
minimal advice plus
transdermal nicotine
patches (8 weeks).
Intervention group:
individual counseling
intervention (4
counseling sessions,
1 in-person and 3
over the phone) plus
transdermal nicotine
patches (8 weeks)
1 month–3 months Headand neck,
lung cancer No evidence to support
efficacy of the tailored
CBT intervention both
at 1 month and at
3 months follow-up
2010 Thomsen et al. Randomized
controlled multicentre
trial
Primary aim: Evaluating
the impact of brief
smoking cessation
interventions on post-
surgery complica-
tions. Secondary aim:
Assessing the efficacy
of brief smoking cessa-
tion interventions on
quit rates
130 Control group (N = 65):
minimal advice.
Experimental group
(N = 65): brief smok-
ing intervention (moti-
vational interviewing
plus personalized
nicotine replacement
therapy)
No information available Breast cancer Primary outcome: No
observed clinical
impact on postopera-
tive complications. Sec-
ondary outcome: Brief
smoking intervention
administered shortly
before breast cancer
surgery modestly
increased preoperative
smoking cessation
2010 Schnoll et al. Double-blind placebo-
controlled trial
randomized
Assessing the efficacy of
bupropion for treating
tobacco depend-
ence among cancer
patients
246 Control group
(N = 132): coun-
seling (5 sessions),
transdermal nicotine
patches (8 weeks) plus
placebo (9 weeks).
Experimental group
(N = 114): coun-
seling (5 sessions),
transdermal nicotine
patches (8 weeks) plus
Bupropion (9 weeks)
3 months–6 months Mixed cancer sites Bupropion has a low
impact on quitting
rate on patients with
depression symptoms,
but not in cancer
patients without
depression symptoms.
Bupropion is safe for
cancer patients who
smoke (in terms of
bupropion-related
side effects) and may
increase QOL for
patients with depres-
sion symptoms
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Lucchiari et al. SpringerPlus (2016) 5:1136
Table 2 continued
CLINICAL TRIALS 2000–2014
Year Authors Design study Aim Sample Smoking cessation
intervention Follow-up Disease Outcome
2011 Park et al. Pilot study Assessing the efficacy of
a smoking inter-
ventions based on
behavioral counseling
plus varenicline
49 Control group (N = 17):
no information avail-
able. Experimental
group (N = 32):
varenicline (12 weeks)
plus counseling (9
sessions)
2 weeks–2 months Thoracic cancer Varenicline plus coun-
seling increased quit-
ting rate
2012 de Bruin-Visser et al. Method not stated Examining the efficacy
of nursing-delivered
smoking cessation
intervention
145 Nursing-delivered
smoking cessation
program (counseling
plus nicotine replace-
ment therapy)
6 months–12 months Head-and-neck;
Lung; Breast;
Sarcoma; Bladder
cancer
Counseling plus nicotine
replacement therapy
seem to improve
smoking cessation rate
both 6 months and
12 months
2013 Bastian et al. Randomized
controlled trial Assessing the efficacy of
proactive telephone
counseling combined
with a tailored self-
directed intervention
comparing to tailored
self-directed interven-
tion alone
596 Control group
(N = 251): transdermal
nicotine patches.
Experimental group
(N = 245): proactive
telephone counseling
plus transdermal
nicotine patches
2 weeks–6 months–
12 months Lung cancer No difference
2013 Hawari et al. Prospective
observational study Evaluating the absti-
nence rates in cancer
patients that they
underwent to smok-
ing cessation program
210 Tobacco Intervention:
medical counselling,
pharmacologic man-
agement (varenicline
or bupropion), plus
NRT
3- 6 and 12- months lung, urinary blad-
der, head and
neck cancers
and myeloid
leukemia
Abstinence rates declined
with time
3 months: relapse related
to withdrawal
6 months: relapse rated
to personal and profes-
sional stressful
12 months: relapse rated
to personal and profes-
sional stressful
2013 Ostroff et al. Randomized
controlled trial Assessing the efficacy of
short smoking inter-
vention pre-surgical
185 Control group: coun-
seling plus pharmaco-
therapy. Experimental
group: short smoking
intervention pre-sur-
gical plus counseling
and pharmacotherapy
3 months–6 months Mixed cancer sites Short smoking interven-
tion pre-surgical does
not increase quit rates
both in short term
(hospital admission and
3 months) and in long
term (6 months)
Page 10 of 18
Lucchiari et al. SpringerPlus (2016) 5:1136
Table 2 continued
CLINICAL TRIALS 2000–2014
Year Authors Design study Aim Sample Smoking cessation
intervention Follow-up Disease Outcome
2016 Price et al. Randomized
controlled trial Assessing the feasibil-
ity, safety, and effect
on cessation of
varenicline combined
with counseling for
smoking cessation in
patients with cancer
132 Group 1: 12 weeks of
varenicline followed
by 12 weeks of
placebo
Group 2: 24 weeks of
varenicline
All Participants also
received behavioral
counseling consist-
ing of one 60-min
in-person pre-quit
counseling visit at
week 0 and further
in-person counseling
sessions at weeks 1, 4,
8, and 12
12 weeks Mixed cancer cites 40.1 % of patients
self-reported to be
abstinent at 12 weeks.
Abstinence correlated
with improvement in
cognitive functions
Page 11 of 18
Lucchiari et al. SpringerPlus (2016) 5:1136
TFCs containing nicotine can be considered a NRT,
albeit with specific and distinct characteristics. Firstly,
comparing TFCs with traditional NRTs, the former
deliver a modest amount of nicotine (Fagerström and Eis-
senberg 2012). Secondly, TFCs present a better usability
and they are more appealing for smokers since they can
be used when needed by a well-known modality, i.e. tak-
ing a cigarette-like device to the mouth and inhaling. In
doing so, smokers not only may react to an immediate
need or desire, but they can enact a gesture associated
with their previous status (cigarette smokers), thus elicit-
ing positive emotions and satisfying psychological expec-
tations. irdly, TFCs may be used adlibitum enabling
patients to feel free to control their behavior instead of
feeling an under external imposition. For these reasons,
it has been suggested that TFCs fit in very well with both
the psychological and physiological needs of smokers
who want and/or need to stop.
Some clinical trials revealed that e-cigarettes attenu-
ate the craving for cigarettes (Wagener etal. 2012; Bul-
len etal. 2013). Furthermore, a recent review of the field
showed that TFCs may be considered safe, with few
adverse events and limited toxicity (Farsalinos and Polosa
2014). In the general population, nicotine TFCs has been
showed to be more efficacious in reducing withdrawal
symptoms than nicotine-free TFCs (Etter and Bullen
2011). However, also the latter may be considered valid
options in oncology settings when supported by coun-
selling, as shown by ongoing studies (Cipolla 2012; Luc-
chiari etal. 2016). e use of nicotine-free TFCs allow
drug-free smoking cessation treatments, and this fact
could be particularly interesting for patients undergo-
ing aggressive therapies or at high risk for cardiovas-
cular events. ough some others studies did not find
and effect of the use of TFCs in a population of cancer
patients (e.g. Borderud et al. 2014; Barton 2015), we
argue that only long run longitudinal studies on targeted
population and using randomized design will clarify the
role of TFCs devices to help patients to quit smoking.
At the time of publishing, there is a clear gap in the
knowledge about the feasibility, efficacy and safety of
TFCs in oncology settings. In consideration of the lack
of evidence, it is not possible to recommend a systematic
use of TFCs with cancer patients (Cummings etal. 2014).
However, a number of studies are now open on over the
world. At our institution, two trials are currently ongoing
to analyse how TFCs with and without nicotine might be
included in clinical protocols both during cancer treat-
ments and in early diagnosis screening programs.
Lastly, the pharmacological approach to smoking cessa-
tion is mainly based on two medications: bupropion and
varenicline, both of which are extensively used in clini-
cal practice. Bupropion is an atypical antidepressant that
promotes cessation probably by reducing the stimulating
effect of neurotransmitters, being an inhibitor of dopa-
mine and norepinephrine reuptake. It counteracts crav-
ing and smoke-related withdrawal symptoms (Jorenby
et al. 2006). In addition, it counters emotional distress
during abstinence, which is a very important character-
istic to consider for cancer patients. Indeed, as noted
above, cancer patients frequently experience high levels
of depression, and smoking interruption can drastically
increase this because of psychological and physiological
cigarette dependence.
Bupropion has been administered to cancer patients
during treatment, and it was found to improve their
mood, facilitating the smoking cessation success. In par-
ticular, Schnoll et al. (2010) designed a double-blind,
placebo-controlled trial ran on a sample of 246 cancer
patients (mix cancer sites). In the first arm of the study,
patients received 5 counseling session, 8weeks of NRT
and 9weeks of bupropion. In the second arm, patients
received the same treatment of group 1, but bupropion
was substituted by a placebo. While NRT and counseling
was found to be effective in non-depressed patients,
bupropion showed to be beneficial for those patient who
reported depressive symptoms. Benefits were found both
for mood and for smoking cessation rate.
Bupropion has other relevant properties, e.g. it reduces
post-cessation weight gain (Martinez etal. 2009), and it
can be used even with patients with cardiovascular prob-
lems. However, the use of bupropion should be avoided
for patients receiving active treatments for brain or other
central nervous system cancers, and for those patients
with a history of seizures, bulimia or anorexia nervosa.
Furthermore, the use of this agent must be carefully
weighed when dealing those patients receiving chemo-
therapy with direct CNS effects due to the increased
potential for seizure. More research in the safety of
bupropion during cancer therapy is warranted, even
though no further contraindications are suggested (Klo-
sky etal. 2007).
A further pharmacological treatment for smoking
dependence involves the use of varenicline. is is a
partial agonist of nicotinic acetylcholine receptor sub-
type α4β2, reducing dopamine stimulation. A study by
Gonzales etal. (2006) reported that a 12-weeks vareni-
cline-based treatment counters craving, urgency and
withdrawal symptoms in healthy smokers. If properly
administered, varenicline causes cigarettes to lose their
habitual pleasure, favouring the extinction of the smok-
ing habit (Baraldo etal. 2012; Ebbert etal. 2010). is is
particularly true for smokers with a low motivation to
give up and/or with important nicotine withdrawal symp-
toms (Nides 2008). In the general population, varenicline
is considered the best option to increase the probability
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Lucchiari et al. SpringerPlus (2016) 5:1136
of success of a smoking cessation program, reaching a
25–30% of abstinences within the first year (Issa etal.
2013; Mills etal. 2012). However, a study by Hawari etal.
on a heterogeneous sample (n=199) of cancer patients
(mix cancer sites) failed to find any significant advan-
tage by the use of varenecline in association with NRT at
3months with respect to NRT alone.
Nausea, abnormal dreams, upper respiratory tract
infection and insomnia are the most commonly reported
adverse events, and these are generally mild and self-lim-
iting. Although it has been associated with depression,
suicidal behaviour and myocardial infarction (depres-
sion is actually a relative contra-indication; Brophy 2011),
a recent meta-analysis showed that there is no clear
evidence that these side-effects are causally related to
the drug use (Prochaska and Hilton 2012). Varenicline
should be avoided with pregnant, nursing, in patients
with renal impairment or patients younger than 18, but
generally appears safe in treating tobacco dependence
of patients with cancer. Furthermore, the use of vareni-
cline seem to support cognitive functions (Clinical Prac-
tice Guidelines in Oncology: Smoking Cessation 2015).
In particular, a recent study by Price etal. (2016) on a
sample of 132 smokers with a diagnosis of cancer found
that varenicline was well tolerated by patients. ey
designed a two arms randomized study. Patients received
or 12weeks of varenicline followed by 12weeks of pla-
cebo or a full 24weeks of varenicline. However, at the
moment of publication only data about the first 12weeks
of varenicline are available. e pharmacological treat-
ment was combined with five standardized brief smoking
cessation counselling sessions. About 40.1% of smokers
stopped after 12 weeks of treatment, a datum compa-
rable with results found in the general population. Side
effects symptoms were present (in particular, nausea and
sleep problems) but they did not prevent patients to com-
plete the treatment. Furthermore, abstainers at 12week
showed a significant decrease in cognitive deficits. e
authors did not report data about longer-term assess-
ment points and the placebo condition. Furthermore, the
cancer stage is very heterogeneous (in the 33.3% is not
specified) and many patients (25.8 %) are in remission.
Under this condition is difficult to evaluate the real ability
of patient to tolerate the treatment side effects.
e use of vareniclin in oncological setting require
more research in order to establish in which context it
should be beneficial.
Cognitive behavioral interventions (CBIs)
Cognitive behavioral interventions (CBIs) are based on a
psychological approach to smoking aimed at supporting
people in changing their behavior by a cognitive restruc-
turing. Low-intensity or high-intensity interventions may
be used. e low-intensity interventions are more fre-
quently used in oncology settings, in screening programs
as well as in other clinical settings. ey are character-
ized by self-help tools and the use of so-called minimal
advice. Normally, the self-help tools are booklets, bro-
chures, and informative paper-based support materials,
although video clips and computer-based tools are also
now available. ese tools convey general information
about the consequences of smoking and the benefits of
giving up.
e main advantage of self-help tools is that they target
a large population; unfortunately, their effects are gener-
ally poor (Lancaster and Stead 2005).
e minimal advice is a short list of recommenda-
tions, requiring just some minutes, focused on why it
is important to consider to stop smoking and how (and
where) it is possible to address the issue, e.g. starting an
antismoking program. is approach is particularly use-
ful in a clinical setting, where trust between patients and
physicians is already established and where external but
affordable resources are available (e.g. an antismoking
center).
When meeting a patient, oncologists and/or nurses
may merely explain the importance of interruption of
smoking in cancer care and the impact on treatment,
but they do not directly suggest strategies or therapies
(Emmons etal. 2013).
e minimal advice consists of the evaluation of the
personal smoking history and a few suggestions. Sev-
eral studies reported a delay of specific interventions for
patients who smoke after the diagnosis, probably due to
a “beating the disease” priority. e urgency of the dis-
ease focuses the doctor’s attention on the assessment and
the cure of clinical conditions, while other aspects may
go untreated.
e high intensity interventions involves a counseling
approach. Behavioral counseling has been defined as a
relationship between an expert and a client, focused on
behavior to be changed. Normally, each session lasts
15–30min.
A broadly used tool is the motivational interview aimed
to understand the subjects position within the so-called
cognitive spiral of change (Prochaska and DiClemente
1983), and to activate motivational drivers. Previous
research has stressed that a high motivational level can
facilitate smoking cessation and abstinence, while a low
motivational level negatively affects the success rate. e
motivational level is considered as a benchmark to decide
which strategy to opt for.
Behavioral counseling can be used in oncology settings
and continued during the follow-up scheduling. Gener-
ally speaking, behavioral counseling starts during the
hospitalization and should be continued after discharge.
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Lucchiari et al. SpringerPlus (2016) 5:1136
It has been shown that it increases the giving-up rate
after 6 and 12months (Rigotti etal. 2008) in hospital-
ized patiens. Another widespread model, very useful in
hospital settings, is telephone counseling. Habitually, it
is used in combination with traditional (on-site) coun-
seling (Stead etal. 2006). is intervention can be proac-
tive or reactive (Lichtenstein etal. 1996). e proactive
approach targets patients already prompted to give up,
and then may be used to monitor the ongoing situation
over time. Instead, the reactive approach is based on spe-
cific needs of patients (Stead et al. 2008). A review on
telephone counselling has stressed that it sustains absti-
nence in the long run (Tzelepis etal. 2011). e smok-
ing cessation counseling should be accompanied by a set
of recommendations regarding the need of a general-
ized lifestyle change (Anderson etal. 2002). is aspect
of counseling could be very important in oncology set-
ting, since physical activity may have a positive impact on
quality of life and wellbeing (Gill etal. 2013), thus poten-
tially acting as the trigger of a virtuous circle. Health
personnel could use their privileged role to encourage
changes in this direction and redirect patients to exter-
nal services after discharge. Generally, speaking coun-
seling may be considered effective in supporting smoking
attempts in oncology settings in association with smok-
ing cessation aids (Klemp etal. 2016). For instance, Park
etal. (2011) studied the effect of antismoking counselling
in association with a pharmacological tobacco treatment
(Varenicline) in a sample of 49 cancer patients with a
thoracic cancer, showing the positive impact of this com-
bined treatment. In this study, the intervention consisted
in a 12-week program (Varenicline and counseling).
Patients in the treatment group received a median of 9
counseling sessions structured according the 5 As brief
counseling model (Ask, Advise, Assess, Assist, Arrange
follow up). Authors report that the prevalence abstinence
rate at 12week follow-up was 40.6 in the intervention
group and 14.3 in the control group.
Similar results were obtained by de Bruin-Visser etal.
(2012) using a 1-year minimal intervention counseling
program delivered by nurses (one visit a week in the first
month and one every other month with the endpoint at
12months). Authors included in their study 145 patients
with mix cancer sites and found a positive effect of the
counseling, since at 6months the 40 % of patients had
stopped smoking, and 33% was abstinent at 12months.
During this period, most patients also use some kind of
nicotine substitutes (83%), but authors report no associ-
ation between abstinence and the use of nicotine replace-
ment products. However, Bastian etal. (2013) failed to
find any positive relationships between a telephone-
based counseling program and smoking cessation in a
large sample of 596 lung cancer patients. In particular,
authors compared an at-distance counseling program
(6 calls) based on motivational interviewing techniques
with tailored self-directed materials (n = 245) and a
minimal intervention based only on tailored self-directed
materials (n  = 251). In both groups nicotine patches
was al used if not contraindicated. eir results showed
no differences between the two groups, even though in
younger patients (<50) the abstinence rate was higher
(16 vs. 4%) at 2weeks post-surgery. is study underline
once more that lung cancer patients need intensive inter-
ventions to stop smoking.
Other studies have tested the efficacy of a strategy
based on a brief physician intervention, showing that
low intensity intervention have poor power in helping
patients quitting attempts. In particular, Schnoll et al.
(2003) compared two large groups of patients (mix can-
cer sites). e intervention group (n = 217) received
a minimal advise and information about the benefits of
quitting and smoking cessation treatment. Furthermore,
patients in this group received a self-help smoking ces-
sation guide a telephone line for additional assistance or
information. e control group (n=218) received only
a minimal advise about smoking by their physician. At
6months, 14.4% patients in group 1 and 11.9% in group
2 had stopped smoking, showing no significant differ-
ences between the two arms of the study.
ough the studies we have considered did not directly
analyzed the cost-effectiveness of smoking cessation
treatment in oncology settings, de Bruin-Visser et al.
(2012) suggest to estimate cost-effective analysis for can-
cer patients using by studies in the general population. In
particular, Song etal. (2002) found that NRT for smok-
ing cessation is cost-effective. e results of the deci-
sion analyses indicated that, as compared with advice
or counseling alone, the incremental cost per life-years
saved is about $1441–$3455 for NRT, $920–$2150 for
bupropion, and $1282–$2836 for NRT plus bupropion.
e cost-effectiveness of adding NRT and bupropion to
advice or counseling for smoking cessation is better than
many other accepted health care interventions. Hoogen-
doorn et al. (2010) analyzed the long-term cost-effec-
tiveness in patients with chronic obstructive pulmonary.
ey reported that pharmacological treatments in com-
bination with intensive counselling was cost saving com-
pared with intensive counselling alone, and that the latter
in turn was more effective than minimal intervention.
Finally, Meenan etal. (1998) analyzed the cost-effective-
ness of a hospital-based smoking cessation intervention
reporting that the cost of the research intervention was
$159 per smoker, and incremental cost per incremental
quit was $3697. Incremental cost per incremental dis-
counted life-year saved ranged between $1691 and $7444,
much less than most other routine medical procedures.
Page 14 of 18
Lucchiari et al. SpringerPlus (2016) 5:1136
Conclusions
A cancer diagnosis may represent a fundamental teach-
able moment for smokers, leading them to give up
smoking or to significantly reduce daily cigarettes. Most
former smokers declare that they decided to quit due to
physical issues or the fear of future health consequences
of smoking (Gallus et al. 2013). Furthermore, a regres-
sion analysis on 15,489 smokers participating in lung
cancer screening studies reviled that smoking cessation
is strongly associated with screening abnormalities and
that efficacious smoking cessation programs should be
integrated within screenings (Tammemägi etal. 2014).
Despite this evidence, few studies have directly addressed
the problem of how to help a patient with cancer to aban-
don unhealthy habits. Additionally, even though some
recommendations exist, no specific and validated pro-
tocols are recognized as a valid and shared antismoking
approach in oncology settings. As a consequence of this
attitude a cancer patient is rarely concretely and system-
atically supported in a smoking cessation journey (e.g.
Nayan etal. 2011; de Bruin-Visser etal. 2012), with the
result that though many patients developed a good moti-
vation to stop, few actually remain abstinent in a long
run. us, the emotional trigger of the diagnosis and the
motivational context of the clinical setting succeed only
in helping patients to suspend cigarette smoking for a
short period (e.g. Land etal. 2011) but not as a sound
lifestyle change.
From a psychosocial point of view, the fact that motiva-
tion to stop level regresses to its pre-diagnostic level is an
expected phenomenon (Slovic etal. 2004). Indeed, emo-
tions have a time-limited effect and their impact on deci-
sion-making processes (e.g. whether to attempt quitting
or not) rapidly fades after an emotional burden. Emotions
must be considered as short-time cognitive modulators,
being able to focus attention on risk-related behaviors
and the need to avoid them in a specific spatial and tem-
poral context (Pravettoni etal. 2012). Consequently, time
matters, since the more time pass between diagnosis and
treatments the more the motivation to quit decreases.
Furthermore, in order to help oncology patients to
reduce smoking-related risks, it is vital to know the gen-
eral characteristics of the context in which the emotions
arose. If a patient learns in a specific, clinical setting (a
surgery and/or oncology department) that smoking is
dangerous and that quitting could be a good solution
for their future health, this setting will be associated
with that emotionally-laden knowledge. Consequently,
patients will develop a situated learning that will moti-
vate their choices. However, when a patient goes back
home the context will dramatically change, activating
previous learning and habits, e.g. smoking while watch-
ing TV or after dinner. Here the motivation to quit will
rapidly vanish if not adequately supported by prior inter-
ventions and adequately sustained by a continuous help,
e.g.by a telephone counseling. Actually, in a study on 721
lung cancer survivors, smoking cessation success was
found to be negatively associated with smoking exposure
at home (Eng etal. 2014).
Consequently, we argue that in order to help patients
to give up smoking, the health personnel working in
oncology settings should be prepared to offer a com-
plete program aimed at promoting health by integrating
new perspectives and attitudes in patients’ values sys-
tem. Cancer centers should promote smoking cessation
applying guidelines and doing more research on smokers’
needs in order to implement tailored and effective inter-
ventions (Mazza etal. 2010; Cataldo etal. 2010).
In particular, even if it is very important to consider
the cancer treatment a teachable moment to help a con-
crete lifestyle change, we claim that emotions should not
be used as levers to force their change, but only as initial
triggers. Indeed a social-cognitive approach to patients
suggests that physicians and nurses should use their posi-
tion within the clinical setting to drive patients through
a sound learning process, instead of causing just a time-
limited suspension of a dysfunctional behavior. In par-
ticular, a cognitive perspective should be used in order to
understand which personal beliefs sustain the smoking
behavior, since biased evaluations could prevent patients
success in their attempts to quit (Masiero et al. 2015;
Pepper et al. 2014). However, to achieve this aim the
hospital personnel should be educated by specific train-
ing and motivated to adopt the best practices by hospital
initiatives.
Overcoming the limits of the classical minimal advice
approach, which could be just the initial part of a more com-
plex process, the social-cognitive intervention should be:
Integrated the smoking cessation treatment should
be experienced as an integral part of the cancer man-
agement. In particular, nurses could serve this aim by
introducing the issues of smoking and smoking cessa-
tion and by evaluating the tobacco dependence and the
motivation to stop so to address patients to dedicated
services.
Personalized the therapeutic options provided to
patients should be compatible with their values, needs
and attitudes. Furthermore, it should address a whole
lifestyle change.
Proactive offering patients continuity in treatments,
avoiding offering merely on-demand support or sugges-
tions.
Reactive providing patients dedicated treatments or
support when needed, independently of any therapeutic
scheme.
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Lucchiari et al. SpringerPlus (2016) 5:1136
is approach requires a multidisciplinary effort since
physicians, nurses and behavior change specialist should
work together each having specific roles (Lucchiari etal.
2013). In particular, physicians should introduce the issue
of smoking within the general treatment, using the ther-
apeutic alliance to gain the attention of the patient and
guide the subsequent cognitive assessment of smoking-
related risks and benefits of quitting. Some studies (e.g.
Mazza et al. 2010) have reported the fear of physicians
to suggest antismoking programs due to the fragile emo-
tional situation of patients, and the potential to cause
distress responses. Nonetheless, an antismoking path-
way should not be experienced by patients as a further
stressor, and we suggest that health personnel could play
a vital role in helping patients to approach the problem in
a balanced fashion, to reduce stress and maximize bene-
fits. Since a number of studies on cancer patients demon-
strate moderate smoking cessation success following the
general principles of evidence-based smoking cessation
protocol (Gritz etal. 2014) a targeted and interdiscipli-
nary approach should be adopted using systematic moni-
toring of patients’ needs and behavior in order to sustain
long-term abstinence (Hawari et al. 2013). However,
when this is not possible, physicians and nurses should
act as valuable information carriers, addressing relevant
issues and encouraging patients to search for support in
external services.
Health personnel should provide detailed informa-
tion about smoking hazards (both before, during and
after cancer) and support patients’ motivation to start an
attempt to quit (Zwar etal. 2011). is support should
be based on a social-cognitive perspective, since any
information and/or advice provided should be aimed at
breaking down false beliefs and cognitive biases and at
reinforcing the emotional, physical and social benefits
of the change. Consequently, personnel should be well
trained in performing this task and they should be aware
of the important role they are playing in the whole pro-
cess. is mean that physicians and nurses are regarded
not only as information bearers, but also as change
facilitators, potentially making a great difference in the
result (Cooley et al. 2008). Finally, specialized counse-
lors should follow the entire clinical pathway by regular
meeting (potentially also at a distance, e.g. by telephone)
to provide emotional support, sustain motivation, and
approach specific concerns. is should also include
behavioral interventions (e.g. helping patients to manage
anxiety states, sleep disturbances and the like).
Physicians, nurses and specialists must therefore work
in an integrated fashion, able to exchange informa-
tion, keep track of the patients’ history and adequately
respond to patients’ demands throughout all the oncol-
ogy treatment. is also means that when patients need
help, e.g. in the use of antismoking medications or in
following specific procedures, they can easily find prac-
tical support, as some studies have shown that patients
often fail to continue the antismoking treatment due
to practical problems (e.g. McBride and Ostroff 2003).
Indeed, a whole and integrated approach will get patients
into a protection context, where emotional, behavioral
and practical issues are continually monitored and sup-
ported. However, the future success of tobacco smoking
programs in oncology settings will depend on the level of
knowledge education and motivation of health personnel.
Authors’ contributions
CL and MM searched for and collected the scientific literature to work under
the supervision of GP and, for the oncological and pharmaceutical studies,
AB. All papers were discussed and commented by all authors. The article text
was drafted by CL and MM and then amended by others. All authors read and
approved the final manuscript.
Author details
1 Department of Philosophy, Università degli Studi di Milano, Milan, Italy.
2 Department of Oncology and Hemato-Oncology, Università degli Studi di
Milano, Milan, Italy. 3 Applied Research Unit for Cognitive and Psychological
Science, European Institute of Oncology, Milan, Italy. 4 Department of Neu-
rooncology, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy.
Competing interests
The authors declare that they have no competing interests.
Received: 9 October 2015 Accepted: 8 July 2016
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... Smoking tobacco and, to a lesser extent, e-cigarettes is well-known to negatively influence cancer's prognosis and forms a major risk factor for various cancer types and several other chronic diseases [90][91][92]. Smoking cessation has a favourable effect on treatment efficacy, psychological well-being and general quality of life [93]. The National Comprehensive Cancer Network offers a guideline for smoking cessation, consisting of pharmacotherapy (e.g., nicotine replacement therapy or varenicline) and behaviour therapy ( Figure 2) [47,94]. ...
... This can be explained by the fact that nicotine produces an acute analgesic effect, making it much harder for them to stop due to the rewarding sensation they experience [99]. Despite its short-term analgesic effect, tobacco smoking sustains pain in the long-term [93]. This underlines the importance of incorporating antismoking medications in CSs with pain to avoid relapse during nicotine withdrawal [99]. ...
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ARCTT is a peer-reviewed all-purpose journal covering a wide variety of topics of interest to the mental health, neuroscience, and rehabilitation communities. The mission of ARCTT is to provide systematic, periodic examinations of scholarly advances in the field of CyberTherapy and Telemedicine through original investigations in the telemedicine and cybertherapy areas, novel experimental clinical studies, and critical authoritative reviews. It is directed to healthcare providers and researchers who are interested in the applications of advanced media for improving the delivery and efficacy of mental healthcare and rehabilitative services. www.arctt.info
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Background: Smoking is a global public health problem. For this reason, experts have called smoking dependence a global epidemic. Over the past 5 years, sales of electronic cigarettes, or e-cigarettes, have been growing strongly in many countries. Yet there is only partial evidence that e-cigarettes are beneficial for smoking cessation. In particular, although it has been proven that nicotine replacement devices may help individuals stop smoking and tolerate withdrawal symptoms, e-cigarettes' power to increase the quitting success rate is still limited, ranging from 5% to 20% dependent on smokers' baseline conditions as shown by a recent Cochrane review. Consequently, it is urgent to know if e-cigarettes may have a higher success rate than other nicotine replacement methods and under what conditions. Furthermore, the effects of the therapeutic setting and the relationship between individual characteristics and the success rate have not been tested. This protocol is particularly innovative, because it aims to test the effectiveness of electronic devices in a screening program (the COSMOS II lung cancer prevention program at the European Institute of Oncology), where tobacco reduction is needed to lower individuals' lung cancer risks. Objective: This protocol was designed with the primary aim of investigating the role of tobacco-free cigarettes in helping smokers improve lung health and either quit smoking or reduce their tobacco consumption. In particular, we aim to investigate the impact of a 3-month e-cigarettes program to reduce smoking-related respiratory symptoms (eg, dry cough, shortness of breath, mouth irritation, and phlegm) through reduced consumption of tobacco cigarettes. Furthermore, we evaluate the behavioral and psychological (eg, well-being, mood, and quality of life) effects of the treatment. Methods: This is a prospective, randomized, placebo-controlled, double-blind, three-parallel group study. The study is organized as a nested randomized controlled study with 3 branches: a nicotine e-cigarettes group, a nicotine-free e-cigarettes group, and a control group. The study is nested in a screening program for early lung cancer detection in heavy smokers. Results: The study is open and is still recruiting. Conclusions: Stopping or reducing tobacco consumption should be a main goal of any health organization. However, traditional antismoking programs are expensive and not always effective. Therefore, favoring a partial or complete shift to e-cigarettes in heavy smokers (eg, persons at high risk for a number of diseases) could be considered a moral imperative. However, before following this path, sound and reliable data on large samples and in a variety of contexts are required. Trial registration: Clinicaltrials.gov NCT02422914; https://clinicaltrials.gov/ct2/show/NCT02422914 (Archived by WebCite at http://www.webcitation.org/6etwz1bPL).
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Background: Continuing to smoke after a cancer diagnosis can adversely influence the prognosis for patients with cancer. However, remarkably few studies have carefully examined the use of first-line FDA-approved medications for nicotine dependence in patients with cancer. This study evaluated the feasibility, safety, and effect on cessation of varenicline for smoking cessation in patients with cancer. Methods: Data from 132 treatment-seeking smokers who received 12 weeks of open-label varenicline and five brief behavioral counseling sessions were used to evaluate the feasibility, safety, and impact on cessation of varenicline. The effects of abstinence on cognitive function and affect were also explored. Results: Of 459 patients screened, 306 were eligible for the study (66.7%) and 132 entered treatment (43.1%). Retention was 84.1% over 12 weeks. The rate of biochemically verified abstinence at week 12 was 40.2%. Expected side effects were reported (e.g. sleep problems, nausea), but there were no reports of elevated depressed mood, suicidal thoughts, or cardiovascular events. Abstinence was associated with improved cognitive function and reduced negative affect over time (p < 0.05). Conclusions: Although many patients with cancer who smoke did not enroll in treatment, the side effect profile of varenicline and its effect on short-term cessation converge with what is seen in the general population. Further, as with the general population, abstinence while taking varenicline may lead to improved cognitive function and reduced negative affect. The present data support the use of varenicline to help patients with cancer to quit smoking. Copyright © 2016 John Wiley & Sons, Ltd.
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Purpose: The purpose of this systematic review was to describe the efficacy of smoking cessation counseling and the resulting quit rate in patients with head and neck cancer. Materials and methods: A systematic literature search was conducted in the PubMed, Embase, and Cochrane databases. Predictor variables were smoking cessation counseling and smoking cessation interventions. The outcome was smoking cessation. Data collection and quality assessment were performed independently by 2 of the authors. Selected publications were assessed for potential risk of bias, and the level of evidence was evaluated using National Health and Medical Research Council guidelines. Review Manager 5.3 was used to conduct the meta-analysis. Results: Eight studies involving 1,239 patients were included (3 randomized controlled trials, 3 cohorts, and 2 case series). Smoking cessation was achieved considerably more often in patients who received smoking cessation counseling compared with those who received usual care. Conclusions: This review shows that counseling supplemented with nicotine replacement therapy increases the possibility for smoking cessation in patients with head and neck cancer.
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