Nicotine Dependence
Current Treatments and Future Directions
Summary of Key Points
Prevalence of Tobacco Use and Nicotine Dependence in Patients with Cancer
• Approximately one in five American adults is a current smoker.
• Smoking accounts for one third of all cancer deaths.
• Patients with cancer in general have a higher dependence on nicotine and are more likely to be smokers or ex-smokers.
• Approximately 15.1% of adult cancer survivors are current smokers.
Current Treatment Recommendations
• Nonpharmacologic treatments include behavioral counseling (e.g., identifying triggers and managing withdrawal), quitlines, and self-help material (e.g., booklets and videos).
• Nonpharmacologic approaches are popular but yield relatively low quit rates.
• Pharmacologic treatments approved by the U.S. Food and Drug Administration, including nicotine replacement therapies (e.g., transdermal patch, gum, nasal spray, inhaler, and lozenge) and bupropion, have been shown to double smoking cessation rates compared with placebo. Varenicline is the newest agent, with efficacy superior to that of nicotine replacement therapies and bupropion.
Smoking among Cancer Patients
• About half of patients with cancer continue to smoke after diagnosis, even though tobacco use complicates cancer treatment, reduces survivorship rates, increases the risk for a second primary tumor, and diminishes quality of life.
• Few studies have examined predictors of continued smoking among patients with cancer, but some studies have reported on such factors as nonsmoking-related cancers, comorbid depression, and poor prognosis.
• Several retrospective studies have shown the detrimental effect of continuing to smoke on cancer treatment outcomes. A limited number of randomized controlled trials of smoking cessation treatments have been conducted among patients with cancer. These reports suggest that a combination of medications and a behavioral approach are needed to make a difference.
• Patients with cancer who use tobacco should be treated according to evidence-based treatment guidelines with particular attention to tailoring education about their disease-tobacco link, pharmacotherapy, comorbid medical and psychiatric disorders, and family/household tobacco use.
Barriers to Cessation Treatment in the Oncology Setting
• Health care providers have limited time and expertise to address smoking among patients with cancer, and patients may have comorbid substance use/dependence or other emotional and mental disorders that undermine their ability to quit smoking.
• Systems-level changes and tailored treatment approaches are thought to be needed to lower the rate of persistent tobacco use and recidivism among patients with cancer.
1. The Clinical Practice Guidelines for Treating Tobacco Use and Dependence recommend:
A Systematic screening and ongoing monitoring of tobacco use status
B Adding smoking to the vital signs checkup to ensure proper documentation
C All physicians and health care providers advise their patients who smoke to quit
2. Which of the following statements are true regarding smoking cessation?
A In general, the combination of psychosocial therapies and medication at least doubles the odds of patients quitting smoking.
B The combination of medication and therapy is often needed to make a significant difference in smoking cessation in the oncology setting.
3. Which of the following treatments has not been proven to be effective for smoking cessation?
4. Which of the following describes the reward pathway in the human brain?
A It is an educational system for human learning that was described by the early nineteenth century.
B It is a neurological structure in the human brain that is named after the person who discovered it.
C It is an imaginary concept that is used to describe certain behaviors that relate to addiction and its consequences.
D It is a neuroanatomic pathway that involves dopamine as neurotransmitter, and it is involved with all rewarding activities including food, water, sexual activity, and social affiliation; in addition, it is thought to be involved in the liking process and reinforcing pleasure of all substances of abuse and dependence.
1. Answer: D. The practice guidelines advocate a comprehensive approach to identify and treat all smokers and recommend that health professionals, particularly physicians, make the recommendation to their patients to quit using tobacco.
2. Answer: D. Although medications alone help in smoking cessation, therapy alone also helps, and in delivering both, the success rates for quitting smoking doubles that of each alone. In patients with cancer, it is thought that often both are needed to make a difference because these patients are more dependent on nicotine and are more likely to have more comorbid conditions.
3. Answer: E. Thus far the nicotine vaccine has not been shown to work any differently than placebo for smoking cessation. However, all the other medication options mentioned are validated treatments for nicotine dependence, although clonidine and nortriptyline have not been approved by the Food and Drug Administration for nicotine dependence.
4. Answer: D. The reward pathway is referred to as the neuroanatomic tracks that connect between the ventral tegmental area and the nucleus accumbens and projects to the prefrontal cortex. It is thought to be mediating all pleasurable activities and reinforcing the learning and habituation process for survival and for substances of abuse and dependence.
