by Tom Wilemon

The new Tobacco Control Monograph from the National Cancer Institute (NCI) has key contributions from Hilary Tindle, MD, MPH, the William Anderson Spickard Jr., MD, Professor of Medicine, and associate professor of Medicine at Vanderbilt University Medical Center.

She authored the chapter titled “Implementing Smoking Cessation Treatment Programs in Cancer Care Settings: Challenges, Strategies, Innovations, and Models of Care.”

Tindle emphasized a key word in the monograph title — essential. “This guidance from the National Cancer Institute underscores that treating tobacco is an essential component of comprehensive cancer treatment,” she said.

Different institutions may choose to implement different programs, including electronic health records-based tools that each cancer care provider can use directly.  These include EPIC Smartsets to facilitate prescriptions of proven medications for smoking cessation (such as the nicotine patch or Chantix, the trade name of varenicline).

Some cancer centers include having designated tobacco-treatment specialists embedded within clinics to work alongside cancer care providers. Regardless of the exact program design, a key point is that the treatment of tobacco use should be integrated with the delivery of cancer care.

“At minimum, there are four critical components of tobacco use treatment: (1) identify people who use tobacco, (2) non-judgmentally encourage them to make a quit attempt, (3) offer proven quit aids to support that quit attempt, including counseling and medication, and (4) take these steps while patients are undergoing their cancer care,” Tindle said.

In the U.S., only about 5% of people who attempt to quit smoking — including those with cancer — actually use the recommended medication and counseling. Unfortunately, this lack of support for the quit attempt usually results in continued smoking.

Vanderbilt-Ingram Cancer Center (VICC) has been and continues to be a leader in the treatment of people with cancer who smoke. VICC helped support key electronic health record customizations to facilitate medication use and electronic referral to state quitlines in both Tennessee and Kentucky, where many cancer patients reside.

In addition, with NCI support, Tindle and colleagues at Vanderbilt are conducting a randomized clinical trial of precision medicine to treat smoking. This trial makes use of how fast the liver breaks down nicotine, which can be gleaned from a blood test. Innovative app- roaches like this have the potential to boost the effectiveness of proven medications to quit smoking, while reducing side effects.

People who break down nicotine faster have greater chances of quitting smoking if they are prescribed varenicline. About six to seven  of every 10 smokers break down nicotine quickly. These so-called “fast” metabolizers tend to quit smoking at higher rates if they are given varenicline (Chantix) rather than nicotine replacement therapy.

“The chances of quitting are about double for these faster metabolizers if they use varenicline instead of nicotine patch,” Tindle added. In addition, slower metabolizers benefit from this precision approach to medication selection through lower side effects if they use nicotine instead of varenicline. “So it’s a potential win-win for everyone,” she said.

Precision care for tobacco cessation is not yet standard of care. Tindle hopes that the ongoing study and other studies like it can contribute to future guidelines to improve the treatment of tobacco use.

The NCI monograph, entitled “Treating Smoking in Cancer Patients: An Essential Component of Cancer Care” has several target audiences, including hospitals, cancer centers, physicians and other healthcare providers as well as the general public.

The fact sheet in the monograph provides a quick overview that is especially beneficial to the general public, Tindle said. The monograph is also written in easy-to-understand language and provides people with cancer who smoke and their families an overview of what they should expect from a tobacco cessation treatment program, she said.