Magdalena Sedzinska. She's a psychologist, a psychotherapist, and a senior researcher, and the director of Smoking Cessation Service at the Maria Curie National Research Institute of Oncology in Warsaw. So she has published in over 20 scientific publications, seven books and chapters, and given multiple oral presentations and conferences as well. So without further ado, she's going to be presenting on smoking cessation in different patient groups and whether or not there is a personalized strategy. Thank you very much. Thank you for introducing me. Despite the fact that we know everything about the harmfulness of tobacco smoking for many, many years, and this knowledge is very well established, it does not still result in a public health problem. And tobacco smoking kills every year 8 million people, according to WHO. And it's still the main single cause of premature death worldwide. And cancer mortality is the second reason of death in the world. And smoking has been linked to 15 different cancers. And as we know, it's almost exclusively occurring in smoke and lung cancer. And the International Agency on Research on Cancer in Lyon classified tobacco smoke as carcinogen number one. So there is no safe level of tobacco use. And it applies as well to these heated tobacco products, a new product which we have now with a growing epidemic, especially among young people. Even if it is by FDA classified as a modified risk product, it is still a product with a risk. And despite the fact that tobacco smoking is classified as a, let's say, lifestyle type of risk, there is not only a choice or a personal choice of people, not only the element of lifestyle, because nicotine addiction is a disease, disease with a specific etiology. This is the nicotine addiction. As every disease, it has their own symptoms and treatment as well. So when we can say that someone is not just a smoker and it's not a personal choice, but it's a disease, we make a diagnosis after three months of daily or almost daily smoking. And the disease is the dysregulation of nicotine intake among people who smoke. So what are the symptoms of this disease? This is, of course, the impaired ability to control its use. People decide sometimes every day that from the next day they will stop smoking and they are not just able. The nicotine intake increases its priority over the other activities. There is persistent use despite of harm and negative consequences. Sometimes they just know that they eat harm, but sometimes they already feel the consequences, but they cannot stop. Feeling of need or craving for nicotine, increasing the tolerance to the effects of nicotine. So they need to smoke more and more to have the same effect. And of course, withdrawal symptoms when they start to reduce the nicotine or just stop. And it's important, the withdrawal symptoms are very important in terms of keeping abstinence in the first days or first weeks, because this is the most important factor of relapse. But because smoking becomes a lifestyle choice, in fact, because they smoke in a particular situation, emotional and psychological situation and some social situations, these elements become more important in keeping an abstinence. So that's why we cannot achieve 100% result in treatment. And if someone stops, we say of sustained full remission after 12 months. So because this is the disease, we have a medication. So we have, you can see on the slide, three groups of medications. They are all evidence-based. So it means that they have a trial which proves the efficacy and safety. So we have a nicotine replacement therapy. This is one group. This is nicotine in different forms, like patches, lozenges, gums, and spray or inhaler. And we have antidepressant, which is bupropion. And we have the group of two drugs called partial nicotine receptor agonist. This is varenicline. I made it in gray because it's not available in Europe right now and we don't know when it will be back. And we have a cytosine, which is a herbal drug. Maybe some of you don't know it because it's not available all around the world, but I think it soon will be because there are a lot of studies as well in United States and in Australia and New Zealand. And this is the drug which is, as I mentioned, partial agonist and it's a herbal drug and it's effective and it's much cheaper than the rest of the drug. As I said, it's not only the physical addiction to nicotine, but it is as well psychological and social addiction to all these activities connected with smoking. So we need to add as well the behavioral treatment. We have different methods. The minimal intervention, called PHIA, is the simplest and it doesn't need any special skills. This PHIA, or I prefer, definitely I prefer among the doctors, the AAR, which means ask, advise and refer. Because we know that oncologists, they don't have time to make a treatment of tobacco dependence. So they should ask in a nice, empathic way about smoking and advise, stressing the benefits of quitting, to quit smoking and then refer to the point like smoking cessation clinic or in ideal world, in every hospital, the unit, like smoking cessation unit. We have as well some intensive behavioral support which has a proven efficacy as well. This is the, it can be individual or in group, done in group. It requires, of course, it's more demanding, it requires more skills. And I think about the CBT, cognitive behavioral therapy, motivational interviewing and mindfulness, which has as well a proven efficacy. We can provide as well telephone proactive support by quitlines to our patients and the proactive quitline is, proactive advice from quitline is as well proven. And text messaging, web-based services, social media support. And this is the general scheme. Pharmacotherapy plus behavioral support, which apply to general population. But there are some certain situation with the importance of smoking cessation. And I mean the people diagnosed with chronic disease like lung cancer. So that's why the researchers made a question if there is a special strategy we can apply to different group of patients. So according to Cochrane Library reviews, I've chosen three groups, lung cancer patients, preoperative patients, because it applies as well to lung cancer patients and mental ill patients. So if we think about the lung cancer patients, unfortunately there are no clinical trial, randomized clinical trials that met criteria to include them into the reviews. So we cannot determine whether smoking cessation intervention is effective or whether one program is more effective than any other. But of course we know the benefits of quitting smoking in this group. So it's obvious that we should try to encourage our patients to quit smoking. Preoperative patients, we have some proven efficacy of short-term efficacy of minimal behavioral support plus NRT. And mental ill patients, I've chosen this group because our patients, I mean lung cancer patients, they often feel depressed and they have some symptoms of depression or anxiety or fear. So that's why I've chosen it. And even in this review we could see that adding psychosocial mood management component to a standard smoking cessation intervention increased the long-term cessation rate in smokers. So when we have a patient with chronic disease, we should remember that we meet a special person, I mean in a special condition. So this is usually long-term smoker with high dependence with demonstrate the high level of stress and high level of anxiety. They sometimes, they very often feel guilty because this is the tobacco dependence disease. So, but as well they feel that it's too late to quit. It is important to stress that it's never too late because if it's not too late to start anti-cancer treatment, it's not too late as well to have benefits from smoking cessation. So we should stress it. And they are often not aware of benefits of quitting. They feel it's too late, they don't know anything about, oh, my time is finished. Okay, so this is my last slide. So according to literature, we can as well using some approaches which are effective and this is offering help, not only advice. So that's why I said that this ask, advice, refer is very important because when we only advise, the prevalence of those who make a quit attempt is much, much lower. Sometimes five times, according to some studies, this is five times lower than when we offer treatment. So we should always use the comprehensive approach. So applying pharmacotherapy plus behavioral support. Minimal plus behavioral support. This opt-out referral process means that everybody should be offered with the help until they refuse. We should always use this teachable moment. The diagnosis of cancer is always teachable moment. So it means that the motivation to stop smoking increase. And this time it's not very long. So we should use a particular moment to offer them help because there is a chance to be effective. We rather should educate on health benefits than risk because it's difficult situation. So hearing about, listening about the benefits is much more effective than about next risk. And we should use the stepped model which means that we always should take into account the readiness to quit smoking. And I think that's all. Ah, take home message, I forgot. The most important slide, okay. So although there is a lack of randomized clinical trial in specific group of patients, we always, the Smoking Cessation has proven benefits for anti-cancer treatment and survival. So we always should take an attempt to help people. And the Smoking Cessation strategy should be always personalized, especially in terms of mental status of the person and disease limitations. Thank you so much. Thank you.

Dr. Magdalena Sedzinska

smoking cessation strategies

nicotine addiction

evidence-based medication options

tobacco dependence