Thank you, Stephanie, and I'd like to thank the World Lung Scientific Committee for inviting me to speak today about tobacco control in this session. So the title of my talk today is The Role of the Oncologist in a Cancer Patient's Smoking Cessation. So we know that tobacco use or smoking is a known risk factor for cancer, and we know that up to around 60 to 90 percent of patients with cancer have a smoking history, and this varies depending on the type of cancer a patient may have, where there's some cancers that are more associated with tobacco than others. About 15 to 20 percent of patients with cancer are smoking around the time of diagnosis. What's more concerning, however, is that about a half of patients who are smoking around the time of diagnosis continue to smoke afterwards, and about 15 to 60 percent of patients who quit before they were diagnosed with cancer potentially restart smoking after they're diagnosed with cancer. We know that there are many health benefits towards quitting smoking, as continuing to smoking after diagnosis of cancer can lead to worse treatment outcomes, increased complications from the different modalities of cancer treatment, poor overall survival, and also a negative impact on quality of life. And especially for patients who are potentially cured of their cancer or who have a long-term remission, there are also many non-cancer-related benefits to quitting smoking, including benefits towards cardiorespiratory health. And when we think of things across the cancer care continuum, there are many opportunities for tobacco control. And tobacco control can take place as early as lung cancer screening or screening for other types of cancers. Tobacco cessation operations can take place when a patient is diagnosed with cancer and meets the oncologist for the first time and discuss about a treatment plan where tobacco control can potentially be integrated into their treatment. Tobacco cessation operations can also take place during cancer treatment, where we know that patients who quit smoking have potentially better outcomes, and also during long-term follow-up and cancer survivorship, where we know there are benefits towards cardiorespiratory health and other tobacco-related diseases. In terms of the clinical approach to smoking cessation, the traditional approach usually involves what they call the five A's of smoking cessation, which is to ask about a patient's smoking status, to advise about the benefits of quitting, to assess how ready a patient is towards quitting, and then to assist with cessation support, and then to arrange follow-up afterwards. We recognize that in the oncology setting, sometimes this may be a little bit challenging to accomplish because at the first visit or at a cancer visit, there are many other things that are happening. An oncologist may not have the time to complete all five A's for the tobacco use assessment and treatment. And so there's been an alternative or simplified approach that's been proposed in the literature called the three A approach, where we ask patients about their smoking status, advise them about the benefits of quitting, and then act or refer or connect patients to cessation resources. And that's what many oncology or cancer centers are adopting now as part of their tobacco cessation approaches. And when we look at the perspectives of tobacco control among different oncology clinicians, and this is some work that was done by a colleague of mine, Dr. Warren, where he surveyed clinicians at the World Lung Cancer Meeting as well as at ASCO, what he found was actually that the overall majority of oncologists will ask a patient about their tobacco use, they will also ask if patients are interested in quitting, and they'll also advise patients about quitting smoking as well. However, less than half of oncologists discuss about medications to treat tobacco use, and less than half of them also actively treat tobacco use as well. And when we asked the oncologists about their perceptions on tobacco cessation, the overall majority of the oncologists reported that tobacco cessation, sorry, tobacco does affect cancer outcomes and that cessation should be standard, but many of the oncologists did not feel that they had adequate training to treat tobacco use and that they needed more training in order to do so. And so this is one of the barriers towards implementing tobacco control in cancer care is that clinicians may lack time and training to assist with cessation. And when we start to look at the perspectives from the patient side of things, we did some work at Princess Margaret in 2016 to understand what the patient perspectives are around tobacco use in cancer care. And one of the questions that we had was that sometimes patients with cancer may feel a little bit of a stigma from being asked about tobacco use, and we wanted to understand how comfortable patients were about being asked about tobacco use. And we did a survey about 500 cancer patients during those two years, and we had about 20% of patients who were currently smoking at the time of diagnosis, and 50% of the patients had either a lung or a head and neck cancer, which is one of the more commonly associated types of cancers with tobacco use. We actually identified that the overwhelming majority of patients felt that tobacco use should be asked at the first clinic visit, and this is regardless if the patient was smoking originally at the time of diagnosis or if they had quit smoking. About half of patients felt that tobacco use should be assessed at every visit, but almost all patients unanimously agreed that they were comfortable with being asked about their tobacco use as part of their cancer care, and they actually felt that it was very important that cancer providers were aware if they used tobacco. And when we asked patients about how they want to be assessed on their tobacco use, we identified that most patients wanted to be asked directly about their tobacco use, and fewer patients, I guess other patients were, patients were also open to other methods as well. When we asked when patients should be asked about tobacco use, the overwhelming majority agreed that patients should be asked at the first visit. We also did some survey work before looking at awareness of the harms of continuous smoking as well, as many patients are aware of the association between tobacco and cancer risk, but we're not, we weren't sure if patients were aware about the potential negative impacts of tobacco use on cancer outcomes. We did some surveys from 2014 to 2015, where we surveyed over 1,000 patients during those two years. And we gave patients six statements to ask about whether or not they agreed, disagreed with the statement, or if they self-reported not knowing. And what we identified was that over half of patients actually reported they didn't know that tobacco can negatively impact surgical complication risk, radiation side effects, quality of life on systemic therapy, or how well chemotherapy and radiation therapy worked. And about 20% of patients actually disagreed that tobacco was going to potentially negatively impact those outcomes. We found that about half of patients reported that they were aware that tobacco potentially increased the risk of death and secondary primary cancers, but about half of them also self-reported that they were either not aware or disagreed with that statement. So this actually shows us that there's potentially an opportunity for oncologists to counsel patients with cancer about the potential benefits of quitting. Lastly, around acting, I'm not going to go into too much detail about it, but there are different strategies towards helping patients with quitting smoking. One of the strategies is to try to leverage electronic health record systems, including using best practice alerts and also embedding tobacco screening and referral systems in health record systems. There's also a number of different programs that oncologists can actually refer patients to so that they have a bit more, because of the challenges around time and also training. And this could include strategies like in-person counseling, prescribing pharmacotherapy through pharmacists, potential telehealth or text message support systems, online apps, or potential near virtual reality or augmented reality strategies. The last step around acting is just to ensure that referrals are sent off for patients when they are referred to cessation resources and their connected programs, and also to monitor smoking status and to continue to encourage patients to quit smoking if they're still smoking after the first visit. So to conclude, oncologists can play a very important role in providing tobacco cessation support for patients with cancer. The overwhelming majority of patients agree that tobacco cessation is important and feel that tobacco cessation should occur at least at the first visit. We also identified that many patients with cancer are not aware of potential benefits of quitting smoking, which can provide an opportunity for counseling. And there are many potential resources that patients can refer to in order to help with cessation support, and this can be tailored to the local context of the institution as well as patient preferences. Thank you.

oncologists

smoking cessation

cancer patients

tobacco use

treatment outcomes