Programs May Help Patients Go Smoke-Free After a Lung Cancer Diagnosis

CURE, CURE® Lung Cancer 2021 Special Issue 2,

Studies show that quitting smoking after a lung cancer diagnosis has a huge payoff for patients. Many smoking cessation programs in cancer centers have tools to help patients quit.

Kris Munday was 10 years old when she smoked her first cigarette. Her friend’s mom had packs stashed in her purse and the girls smuggled them. By age 12, Munday was smoking regularly, and in her 20s, she was up to a pack and a half a day. When she moved to Sutherlin, Oregon, with her fiance and retired at age 35, her daily cigarette count doubled to fill the time.

“I no longer had to work in an office environment, which meant I had more time to smoke,” says Munday, a dog rescuer and breeder. “It had gotten so bad that I was waking up in the middle of the night to smoke.” To curb midnight cravings, Munday started wearing a nicotine patch overnight. But in 2014, when she was 45, she developed a horrific cough. Despite multiple rounds of antibiotics and half a dozen X-rays, doctors couldn’t get to the bottom of her coughing fits.

Within months, Munday developed debilitating fatigue and her cough became so aggressive her lungs partially collapsed. Doctors ordered two bronchoscopies at separate facilities to determine the cause of her symptoms, which showed that Munday had a pea-sized spot on her lungs. “I was hospitalized for unrelated gallbladder surgery and the pulmonologist came to my room and said, ‘Kristine, you have lung cancer,’” she remembers.

Lung cancer will affect an estimated 236,000 Americans this year, and cigarette smoking is the No. 1 risk factor for the disease, according to the Centers for Disease Control and Prevention. In the United States alone, smoking accounts for 80% to 90% of lung cancer deaths, with smokers up to 30 times more likely to die from lung cancer than those who are smoke free. The more years a person smokes and the more cigarettes they puff daily, the higher the odds of negative effects. But cigarettes aren’t the only culprit. Tobacco products, including e-cigarettes and cigars, also increase a person’s risk of lung cancer.

“Tobacco harms every organ and system in the body,” says Judith (Jodi) Prochaska, an addiction specialist with the Stanford Prevention Research Center in California. “It can affect wound healing, post-surgical outcomes and the metabolism of medications, including chemotherapy.” In fact, there’s evidence to suggest that nicotine spurs the growth of new blood vessels that feed cancerous tumors. So patients with lung cancer who continue to smoke after receiving a diagnosis are not only more vulnerable to a second lung cancer, but they’re also at higher risk of developing other cancers, such as head and neck, bladder, cervical, stomach and pancreatic.

To make matters more complex, nicotine is highly addictive. “Even patients who have quit smoking for years may crack under the pressure of a lung cancer diagnosis and return to cigarettes,” Prochaska says. To address these challenges, the National Cancer Institute (NCI) developed the Cancer Center Cessation Initiative in 2017 as part of then-Vice President Joe Biden’s Cancer Moonshot initiative. Since then, more than 50 NCI-designated cancer centers have implemented smoking cessation treatment programs.

Major cancer organizations, including the American Society of Clinical Oncology, the American Association of Cancer Research and the Association for the Study of Lung Cancer, say smoking cessation should be standard of care for patients with cancer — and for good reason. The benefit of quitting on survival rates is on par with emerging therapeutics for lung cancer. Unlike smoking cessation, these therapies could cost thousands of dollars and may not be accessible for the lion’s share of patients. But quitting smoking is possible for every smoker, and many smoking cessation resources are completely free for patients.

THE BENEFITS OF QUITTING

Charlie Thurlow was 57 when doctors told him he had stage 3B lung cancer. After months of coughing, weight loss, night sweats and eventually the collapse of his right lung, Thurlow’s doctor ordered a CT scan. “There was an 11-centimeter tumor across the top of my right lung,” says Thurlow, now 70 years old and retired from a publishing career in New York City. “And there was pain there, too. At times, I’d tried to wrap my chest with a knee bandage so I wouldn’t cough so deeply.”

Thurlow had been smoking at least a pack of cigarettes a day for 40 years (more during his college and graduate school years). By the time the pulmonologist said, “It’s cancer, and I think it’s curable,” he was struggling to light up. What had once brought him immeasurable pleasure was now producing excruciating pain. “For the last several weeks before the diagnosis, I was stretching one to two cigarettes over the course of a day because that’s all I could stand,” Thurlow remembers. “I’d light up, suck in a drag or two then snuff the thing out. I’d repeat the process with the same cigarette a few hours later. I could extract half a dozen such episodes from one cigarette.”

Fortunately, ditching cigarettes has an immediate impact on the immune system, producing a dramatic drop in the body’s natural inflammatory response after someone stops smoking. “Getting rid of that inflammatory load before surgery has a profound impact on treatment outcomes,” says Dr. Matthew Triplette, medical director of the Lung Cancer Early Detection and Prevention Clinic at Seattle Cancer Care Alliance in Washington state.

Plus, there’s strong evidence that people who quit smoking after a lung cancer diagnosis do better than those who don’t. “They live longer and they’re less likely to have a recurrence of the cancer after treatment,” says Dr. Nancy Rigotti, director of the Tobacco Research and Treatment Center at Massachusetts General Hospital in Boston. “They’re also more likely to tolerate the treatment and have fewer adverse events than those who continue smoking.” They also lower their risk for getting a second cancer associated with smoking such as head and neck or bladder cancer.

According to a 2021 study published in the Annals of Internal Medicine, of 517 patients with non-small cell lung cancer, patients who stopped smoking lived almost two years longer without disease recurrence compared with patients who continued smoking (6.6 years versus 4.8 years). Smokers who quit also had higher three- and five-year survival rates than those who kept at it. Other research, including a review of 10 studies consisting of nearly 11,000 patients for the 2020 Surgeon General’s Report, suggests that smoking cessation improves treatment outcomes and increases survival among patients with cancer. The longer a person goes without smoking, the lower their year-to-year risk of getting lung cancer becomes.

For the 40% to 50% of patients who are current smokers when they receive a lung cancer diagnosis, these findings may provide much-needed motivation to quit. “When smokers get a lung cancer diagnosis, they sometimes think that the worst has already happened, so why quit,” Triplette explains.

That was certainly the case for Thurlow, who quit smoking as soon as he found out he had cancer. Unfortunately, doctors weren’t sure they could operate because his tumor was attached to the chest wall, but after eight weeks of low-dose chemotherapy coupled with 15 rounds of radiation, the tumor had shrunk. Thurlow became a candidate for surgery to remove the remaining cancer. He went on a high-powered chemotherapy regimen following surgery to ensure the cancerous cells were gone, and he has been cancer free ever since.

THE SCIENCE OF ADDICTION

While the perks of quitting are undeniable, walking away from nicotine isn’t easy. Like most addictions, smoking is entangled in a complex web of physiological and psychological factors. Studies show that about 70% of smokers want to quit, and in any given year, 55% of smokers try to do so.

“With each puff of a cigarette, the feel-good hormone dopamine floods your system, and that keeps you coming back for more,” Prochaska explains. “Plus, if you’re used to smoking when you’re drinking coffee or chatting on the phone, smoking becomes almost Pavlovian. You hear the bell; where’s the drug?”

Despite the massive tumor lodged in Thurlow’s chest and permanent pulmonary damage, he still reached for a nonexistent pack in response to a variety of triggers, such as a ringing telephone. “I had a nagging sense of a hole that I couldn’t fill, an itch that I couldn’t scratch,” he explains. Today, Thurlow is 12 years out and he still hasn’t entirely freed himself of these vague yearnings, and he still loves the smell of cigarette smoke when a waft comes his way.

“Preoccupation with my disease and mortality provided a distraction from withdrawal,” says Thurlow. “Psychologically, a belligerent attitude is an undervalued ally in the great battle, and defying my addiction went hand-in-hand with defying my disease. I had to satisfy myself (with the fact) that I was doing everything within my power to get well, and smoking would have violated that commitment. Smoking would also have betrayed the trust of everyone embracing the cause of my recovery — particularly my wife, but also my children and other family; my oncologist, radiologist, and surgeon; an army of nurses and social workers; and countless friends. Had I smoked, I’d have felt guilty. Not smoking, I could enjoy a clear conscience.”

Munday took a more methodical approach. A respiratory nurse at the hospital where she had gallbladder surgery coached her on how to quit. “She told me that a nicotine craving lasts only three minutes and that you can tolerate anything for three minutes,” she says. “She also explained that it takes three days for your body to adjust to a new level of nicotine. So if you gradually cut back each week, you can be done with cigarettes inside of a month.”

Armed with that information, Munday set out to be smoke free before her first chemotherapy treatment. Every five days, she took half a pack of cigarettes and set it aside, starting by dropping from three packs a day to two-and-a- half packs, and then from two-and-a-half packs to two. She also began chewing ice to fill the void of smoking cigarettes. “It took me three to four weeks to stop smoking completely,” Munday says.

Munday had tried to quit before. She even paid $900 for hypnosis sessions, but her attempt to quit lasted less than a month, in part because her fiance was also a smoker. This time, however, they kept a smoke-free zone on one side of their home, and she used a nicotine pen to take the edge off. “I used the pen part-way through chemotherapy and radiation and then just titrated down my use the same way I had with the cigarettes,” she says.

According to Triplette, a week or even a day without cigarettes before smoking again isn’t a sign of failure. Instead, it shows that they can break the biochemical addiction and be able to do it again. The threat of a cancer diagnosis may even make the idea of quitting more palatable. “Cancer is a teachable moment. Something profound that happens in your life that you can directly tie to a behavior,” says Triplette. “When you make that link for the patient, it can improve the success of their quit attempt.”

TOOLS TO QUIT

After receiving a lung cancer diagnosis, some people can quit more easily than they imagined because smoking becomes physically difficult. But many others struggle
to quit. Navigating cancer is stressful, and many turn to cigarettes when they’re stressed. Yet according to the 2020 Surgeon General’s Report, less than one-third of people who try to quit smoking use evidence-based smoking cessation treatments.

With smoking, there is a very addictive, habit-forming behavior in addition to a substance — nicotine — that is physiologically addictive. To address both parts of the equation, a growing number of comprehensive cancer centers are offering patients a full buffet of options, including evidence-based counseling approaches, medications to help reduce withdrawal symptoms and curb cravings, and nicotine replacement therapy. Cessation programs that combine counseling with pharmacotherapies show cessation rates up to 57% in the first six months after starting the program, according to some studies. “Each of these approaches can work alone but they work better when they’re combined,” Rigotti says.

To give patients who smoke the best shot, many cancer centers incorporate tobacco treatment into standard patient care unless a patient opts out. At Seattle Cancer Care Alliance, for example, patients who indicate they are current or former smokers are automatically connected with the smoking cessation team. They don’t have to worry about getting a referral for treatments like counseling and medication for tobacco dependence.

“Patients may be hesitant to share that they’re smoking or even that they’re former smokers, so we’ve worked hard to overcome barriers around stigma,” Triplette says.
Social workers can also help connect smokers and former smokers with support groups specific to patients with cancer who are trying to quit. Prochaska’s team even uses breath sample analysis to show former smokers how their CO levels have dropped to zero. “That can be motivating both for the patient and for those who are in the group,” she says.

Other avenues of support include the federal government-sponsored quit line (1-800-QUIT-NOW), where a tobacco counselor guides individuals through a quit process through telephone appointments. “Many free resources, including the quit line, also provide nicotine replacement therapies, such as patches, lozenges and gum, to help people quit smoking,” Rigotti says.

For many smokers, that support is critical, and it’s one reason Thurlow became a volunteer with the Cancer Hope Network, a nonprofit organization that matches patients to survivors by diagnosis and treatment. Although he was able to quit cold turkey, he recognizes that it is often harder for most and always suggests hospital-based cessation programs first. “But the best thing I can tell a match is that despite a dreary prognosis, I’ve been cancer free for 12 years, in no small part because I have had a team of supporters in my corner, including my wife and children.”

While Munday’s loved ones, friends and medical team applauded her efforts to quit smoking and reveled in her success, she didn’t have that same support at home. After four total weeks of chemotherapy and 37 rounds of radiation, Munday realized she couldn’t stay with her fiance. “He refused to stop smoking in our home and our cars,” she explains. “There were other reasons, too, but that was a huge one.” She ended the 18-year relationship and moved into her own place a few months after completing cancer treatment.

“When I went back to the oncologist two months shy of my five-year mark, he said, ‘You’re 100% cancer free,’” she says. That was a welcome turn of events for Munday, who was once told that her odds of surviving the disease were 20% to 30%. Could ditching cigarettes be the reason she survived? No one knows for sure. But there’s no doubt that going smoke free has given Munday a second lease on life.

For more news on cancer updates, research and education, don’t forget to subscribe to CURE®’s newsletters here.