Social Determinants of Health – Modifiable Risk Factors – Tobacco Cessation

Social Determinants of Health in Cancer Care

This episode was originally released August 23, 2021

In this Social Determinants of Health (SDOH) episode, Dr. Narjust Duma (DFCI) moderates a talk with Dr. Danielle McCarthy (University of Wisconsin-Madison) and Dr. Erica Warner (Harvard Medical School & MGH) on tobacco cessation as a modifiable risk factor and how clinicians can respectfully engage with their patients on this topic. View COI.

TRANSCRIPT

LORI PIERCE: Hello. I'm Dr. Lori Pierce, the 2020-2021 president of the American Society of Clinical Oncology. Thank you for tuning in for this discussion on social determinants of health and their impact on cancer care. The purpose of this video is to educate and inform. It is not a substitute for medical care and is not intended for use in the diagnosis or treatments of individual conditions.

Guests on this video express their own opinions, experiences, and conclusions. These discussions should not be construed as an ASCO position or endorsement. For this series on the social determinants of health, we invite guests with a wide range of views and perspectives. Some of these conversations may be provocative and some even uncomfortable. But ASCO is committed to advancing equitable cancer care for all individuals. Every patient, every day, everywhere.

I dedicated this vision to my term as ASCO president, and these conversations bring many voices to the table, voices that we need to hear to move forward and find solutions. We hope you learn new ways of thinking about these issues, and we invite you to join us in working toward a world in which every person with cancer, no matter where they live or what resources they have, receives high-quality equitable cancer care. Thank you.

NARJUST DUMA: Welcome to the eighth episode of ASCO Social Determinants of Health Series. I'm Dr. Narjust Duma, and I'm the associate director of the Cancer Care Equity Program at the Dana-Farber Cancer Institute. With me is Dr. Danielle McCarthy, associate director for research and the Center for Tobacco Research and Intervention at the University of Wisconsin-Madison. I also have the pleasure of having Dr. Erica Warner assistant professor of medicine from Harvard Medical School and assistant investigator for Massachusetts General Hospital.

In this episode, we will discuss tobacco cessation as a modifiable risk factor and how clinicians can respectfully engage with their patients on this topic. I would like to thank Dr. McCarthy and Dr. Warner for being here today.

ERICA WARNER: Thank you.

DANIELLE MCCARTHY: My pleasure.

NARJUST DUMA: Moving forward, we address Dr. McCarthy and Dr. Warner by their first name. We're colleagues and friends, and this is a friendly conversation about a very important subject. So we're going to start with a few questions, and they're going to give us their great insightful comments.

First, we want to speak about the stigma with tobacco use. There's a lot of stigma associated with tobacco use and subsequently with lung cancer. This affects all patients, but it can be worse in some communities versus others. Dr. Warner, can you speak to us about this stigma with tobacco?

ERICA WARNER: Yes, certainly. I think stigma is a really important issue. And I'm doing some work around this right now with cancer patients. I think that anti-smoking campaigns have been amazingly effective really at spreading the message that smoking is associated with a long list of negative health outcomes.

I think the most well-known being the link with lung cancer risk. And over time, as smoking rates have declined in the United States-- focus is mainly on the United States, but I think some of these comments are relevant for other places. As smoking rates have declined, you've seen that the populations that continue to have the highest rates of smoking are largely lower socioeconomic populations in the US now.

And so I think this combination of the sense that messaging has told us that smoking is, quote, unquote, "bad," that marginalized populations tend to have higher smoking rates currently, coupled with this idea that smoking is just a poor choice, a bad decision that any given individual is making, leads to smoking and ultimately people who smoke being stigmatized in our society today. And I think there's a lot that we can do to try and combat this, but really focusing on this idea that smoking is a poor personal choice that someone is making.

We know that there has been lots of advertising that has been targeted at specific communities to try and get them to smoke and even now that we're not allowed to have smoking advertisements on TV and on billboards in the way that they used to be, there are still many ways in which these communities are being targeted, as well as recognizing that smoking is an addiction. So there are plenty of people who smoke, who recognize that it can have bad consequences for their health. They don't wish to continue to smoke but are struggling for smoking cessation.

And so I think that really all of us, and as we'll talk later about providers, need to approach smoking and individuals who smoke with more empathy.

NARJUST DUMA: And connected to that question, we have seen marketing that is targeted to certain populations. So while living in the Midwest, I have a very close contact with Native Americans. And the amount of mail these populations receive about smoking, like you turn 16, and you get an advertisement in the mail about here's your first Marlboro package for free.

And this can be for the two of you, how is this targeted marketing that also affected women in the 1970s and '60s in which is smoking was associated with weight loss, like if you want to stay thin or slim, you need to smoke. So how this has affected tobacco in the past and currently now with this targeted marketing to populations.

DANIELLE MCCARTHY: Yeah. I can certainly speak to that in Wisconsin. We see, it's not just marketing at point of sale. There is direct marketing, as you mentioned. There are also just a greater concentration of tobacco retail outlets in certain communities. So there's just more access.

And the Wisconsin African-American Tobacco Prevention Network has done a lot of really great work reaching out to retail sites, convenience stores, corner markets, to try to encourage them to verify a customer's age before they sell tobacco and also gotten them to agree to no menthol Sundays. Like they've had some days where they just won't sell menthol cigarettes because menthol has been so aggressively marketed to African-American communities.

And they've gotten these retailers to agree to this and to buy into this, that this is a social justice issue. It's not just a matter of commerce. It's a matter of equity. And it's really exciting to see that even people who make a little profit on selling tobacco are willing to modify their conduct to address these issues, at least in a small way. And so if we see a menthol ban enacted on a broader scale, that could have a big positive impact.

NARJUST DUMA: Thank you for your comment, Dr. McCarthy. We have seen some changes at the corporate and institutional level, such as made by CVS to stop to sell tobacco. And this is very linked to your comment. What has been the role of health care institutions in promoting tobacco cessation? I know we have talked about also being reactive to be more proactive, but what has changed and what can change still?

DANIELLE MCCARTHY: Right. A lot has changed. We now assess smoking status along with height, weight, and blood pressure. It's now considered a vital sign because it's the leading preventable cause of death. So knowing your patient's tobacco use status and addressing it is really important. Knowing it and doing nothing with that information is not very helpful. And so the next step is really important.

And we know that from population studies that only about half of patients who walk out of a doctor's office walk out and say, yeah, the doctor talked to me about my smoking and offered me something. And so we want to get that up to 100%.

And we think that health systems can implement changes to make that happen. And we've shown that if you integrate some prompts and reminders into the electronic health record, that that can greatly increase the rates at which treatment is offered and that about 12% or so of people who come in off the street for another reason to your clinic will agree to set a quit date within the next 30 days and accept treatment. So that's pretty impressive, right?

So even though the majority of people say they want to quit smoking, that doesn't mean that they want to do it today. But if you ask them today, more than 1 in 10 will probably say, yes, I will agree to treatment. Sign me up. I'm willing to quit within 30 days. So you really can intervene. Health systems can support that by creating workflows that are efficient and effective and connect the patients who smoke with cost low-barrier treatments.

For example, State Tobacco Quit Lines that don't charge for their services and now offer pharmacotherapy and free phone coaching or counseling. So that's something that we've been working on here in Wisconsin. And multiple health systems have now adopted electronic referral to the State Quitline as one of their standard options that they provide for patients who smoke.

The other thing is that 52 cancer centers in the country are now part of an NCI-funded initiative called the Cancer Center Cessation Initiative to more proactively address smoking in cancer settings. And so if you're working in a cancer center, odds are that they're participating in this program and that they're developing some sort of initiative to try to improve the rates of addressing tobacco use among people who present with cancer.

NARJUST DUMA: And the follow-up question, which is a little bit out of script, is have we seen differences in smoking cessation counseling across racial/ethnic groups and across gender? And you can spend a little bit more on this, Dr. McCarthy, if you would like.

DANIELLE MCCARTHY: Yeah. Sadly. We have. And even though we see that motivation to quit is higher among minoritized racial groups in the US and that more quit attempts are actually made among minoritized groups than among white people who smoke, that the rates of achieving cessation are historically lower.

What I think is really exciting about these proactive system changes is we actually have seen higher uptake of treatment among African-American patients, among Hispanic patients in some models, not all models, and especially high uptake among Medicaid-eligible patients, where smoking rates can be as high as 30%, compared to about 14% in the general population.

So where there is great need, there's also great interest in treatment and great receptivity to treatment. And I think that's incredibly exciting and encouraging, that maybe if we were to universally offer cessation treatment, we would see that the treatments were getting where they have not gotten before.

If you just wait for a patient to bring it up, it's not going to be the patient who has the greatest economic stress, greatest social stress who's going to say, you know what's on the top of my agenda today is quitting smoking, it's going to be the most resource to patients who do that.

And so if you want to address these inequities, I think you have to bring it to the patient where they are. And I think that's what's exciting about these system changes. So far, what we've seen is that they seem to enhance equity rather than exacerbate disparities.

ERICA WARNER: I think that's such an important point. And I think it resonates across all of our health equity work, is that if you leave it up to the patient or the provider that has to at each point of interaction make the decision about whether or not to offer something, whether or not to ask for something, that's when disparities creep in. And so we have to make it automated. We have to make it standard of care.

NARJUST DUMA: And that's a very important point. And to our listeners, there are preconceptions that certain populations will not be interested, when in fact, the data has shown the opposite. There are several psychosocial aspects associated with smoking. It is an addiction.

And I think providers should consider that. And this question goes to our guests. How can our understanding of these psychosocial aspects help providers and their conversations about cessation with patients? And now we start with Danielle.

DANIELLE MCCARTHY: It is an addiction. It is a powerful addiction. Untreated, the relapse rates are higher than 90%. It is a relapsing and remitting chronic condition. And there are neuroplastic changes that happen with just a few exposures to nicotine that can be long-lasting. Now, some of those can be reversed by quitting, but they take a long time.

The other thing that is really tricky about tobacco that led us to be confused about whether it was addicting or not for a while is it's not as frankly intoxicating as some other substances. So you don't see a clear intoxication. And the withdrawal symptoms are marked primarily by two things, negative mood and craving. And you don't see the same kind of withdrawal that you see with opioids or even alcohol.

And so for a long time we thought, well, this is just a habit. It is not a habit. There are neuroplastic changes that we know happen and that make it really challenging to quit. And we're asking people to quit in environments in which tobacco is incredibly easy to access. It's still fairly cheap, even considering taxes and price increases. And it's available in the grocery store or the pharmacy and at every gas station.

So it is just embedded in the environment in a way that makes a reliance on willpower and self-control not a great way to go. And so that's why we really advocate for pharmacotherapy to help manage the withdrawal and give the self-control a chance to win in this environment that's really challenging to quit.

ERICA WARNER: I would echo all of that and just add that I think that up front we have to be open and honest with patients, that we recognize that it's an addiction and that it's hard to quit. And that it may take multiple attempts to be successful. And that's not failure. That's a process that you're going towards for a goal.

Because I think it can be disheartening for people who have an earnest desire to quit and find it hard and are not able to on their initial attempts. But we don't want that to be a barrier to continuing to try. And we can support that, as was just described, with medications to help ease some of the symptoms and also trying to provide referrals or other support that can help them address some of the social factors that are associated with smoking.

So if you are trying to quit smoking, and you have someone in your household or multiple people in your household that also smoke, that's going to make it more challenging for you to quit. So to the extent that we can involve the household or the family in smoking, I think that that can help and particularly helps marginalized populations to try and quit.

NARJUST DUMA: Thank you for those comments. And some of the basis for these episodes and podcast is that many of us did not receive training about social determinants of health or how to obtain the information appropriately without being biased or making the patient feel bad about their behavior. So what are some of the comments or questions that providers should completely leave out when addressing smoking cessation or just smoking status? I would start with Danielle.

DANIELLE MCCARTHY: So we like to not start with a yes or no question. Do you want to quit smoking? That's too big an ask. You're going to get too many nos because that sounds scary. That sounds like, are you talking about today?

I don't want to do it today. So we advocate starting it as a conversation. Let's talk about your smoking. I have some resources that I can offer you. I can help you with your smoking. I can offer you medication. I can connect you with counseling. Would you be interested in changing your smoking.

So we're not necessarily saying, let's go from 0 to 60 in three seconds right now, because I got to go to the next patient. We're saying, let's have a conversation. I have something to offer you. Now, let's talk about whether you're interested. So make sure that you get the message across that you have treatment options to share before you ask, are you ready to do this? And sometimes even offer treatment with people who are just willing to cut down.

You could offer treatment to people who are willing to try treatment, even if they're not sure they're ready to quit. That is where we're going with treatment is to say, you don't have to know that I'm setting a quit date on October 1, and that's definitely when I'm going to quit smoking, you could start treatment and see how it goes and then make a decision about whether you're able to go to 0 or whether you just want to cut down by half.

NARJUST DUMA: Erica, which other comments or questions do you think your providers should leave out when addressing smoking cessation?

ERICA WARNER: Yeah I think that there's been a fair amount of work done that shows that positive messaging that emphasizes the benefits of quitting can be more effective than negative messaging that's focused on scare tactics and emphasizing the harms.

I think many people are well aware of the potential harms of smoking, but I think emphasizing that quitting sort of no matter where you are in your experience of quitting, no matter where you are in your cancer journey, for example, among individuals diagnosed with cancer, that there are benefits to quitting. And that, again, we have ways in which we can help support you with medication, with counseling, with other supports that can facilitate this for you.

NARJUST DUMA: Well, thank you to the two of you. We are shortly running out of time. But we want to finish this podcast with tips, because it's very important to share little pearls of wisdom for two of you, experts in the field. I'm no expert. I'm a lung cancer doctor, and I have learned tremendously from the two of you.

So what are some of the tips for providers and also patients or family members to help get these conversations started? And why are we asking for these tips? Because often patients with cancer are not offered smoking cessation counseling. So Danielle, what are one or two tips that you recommend for a provider to get that conversation started?

DANIELLE MCCARTHY: So I would refer people to the National Cancer Center Network Smoking Cessation Guideline, which provides really helpful algorithms. So what do I do if my patient tells me they quit two days ago? So that doesn't mean that they're quit for life? So what do I do with that?

What do I do with someone who's willing to quit within 30 days versus who isn't? And it has a great list of resources and treatment recommendations. These are the pharmacotherapies that are recommended as a first-line, and here are some special considerations for people who are on chemotherapy, et cetera. It's a really great resource.

And also know that there are Tobacco Quit Lines in every state. Every state has a free Tobacco Quit Line available. And that can offer coaching, which can be a great adjunct to the pharmacotherapy that you might provide.

NARJUST DUMA: Erica? A few tips for our listeners.

ERICA WARNER: I don't know that I have that much more to add than what we've said thus far. I would just emphasize this idea of approaching conversations with empathy. I think that we just did some focus groups around women smokers and lung cancer screening.

And we asked them about their interactions with providers around smoking. And many of them described a kind of adversarial interaction, where they felt like the provider was just mainly focused on the fact that they smoked and that was bad and they should quit. And they couldn't really get past that. And I think that's a barrier. It makes patients shut down.

I think providers feel uncomfortable if a conversation is approached that way. And it doesn't end up being useful, I think, for either party. And so, again, I think some of the tips we've shared around empathy, around acknowledging that it's challenging, around making it a conversation about a process as opposed to a one-time let's do it now kind of thing, would all be very helpful.

NARJUST DUMA: Well, thank you for those tips. To our listeners, it's important that we know that we're not doing a good job while addressing smoking cessation with our patients with cancer. We all can do a better job. It is important to practice empathy, like Erica mentioned, and also to avoid yes and no questions, like that Danielle mentioned. Come from a place of cultural humility because it's an addiction more than a choice.

So thank you for joining us for this episode of the Social Determinants of Health at ASCO. To keep up with the latest episodes, please click Subscribe. Let us know what you think about the series by emails to [e-mail]. Thank you, everyone.

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