Next up, we have Associate Professor Marshall, who's a thoracic physician and clinician researcher at the Prince Charles Hospital Brisbane and Faculty of Medicine in the University of Queensland, Australia. Dr. Marshall is a convener of the Thoracic Society of Australia and New Zealand's Tobacco Control Special Interest Group, and has recently joined the IALC, Tobacco Control Committee. Dr. Marshall is a CI on all Australian lung cancer screening trials to date, and has a particular interest in the nexus of smoking cessation and the lung cancer screening. Thank you. Oh, great. Thanks very much for the introduction and thanks for the opportunity to speak today on this really important topic. So just to give you my context, I work in a metropolitan center. I work with a European descent population generally. I work in Australia, which has got highly resourced and well-funded programs. We can give our patients subsidized nicotine replacement therapy, and we've got quit lines, okay? So that's the sort of context. That's not to say that it's a perfect world. There's certainly lots of inequity and difficulties in accessing treatment in Australia. So some of the specifics may not apply necessarily to where you work, but I hope the theme certainly will. And I hope that you'll see that these themes that I use in my practice really echo what's already been said by the excellent talks given so far. So we hear these negative beliefs, these barriers. Why don't we discuss smoking cessation? And can we take these barriers, can we turn them around to be enablers? Yes, absolutely, of course. So it's not too time-consuming. Brief advice works. It doesn't take a lot of time in your clinic to do this. And just thinking about this opportunity, and if we don't take it, what do we do? So at best, if we miss this opportunity, we're not providing good advice to our patients. But at worst, if we don't take this opportunity, what are we saying by this omission of discussing smoking with our patient? Are we kind of implying that it's okay? Are we implying that it's not actually that important? We don't value it, we're not prioritizing it. So what we say is important, and what we don't say is also important. Discussions are ineffective. I think once we understand that this is a chronic, relapsing, remitting disease, then we can understand that we're not gonna maybe make big changes immediately. This is gonna take a lot of time and effort, particularly on the part of the patient. It's gonna take a lot of support from the whole team. And smoking cessation is not a job for a single person in the lung, MDT, to deal with. This is a job for the entirety of the team. And if we think about the time that it may take, 30 or more quick attempts before success, all of those interactions that we could have with our patients in the clinic, and if the whole team can kind of come together with a really unified message that's very supportive, very patient-centered, then that's a very powerful thing. And I think an important thing for our patients, they're in this environment, we're here to help, and we're gonna do this together. We've heard already that quitting smoking at or around the time of lung cancer diagnosis confers a 30% mortality, or sorry, overall survival benefit. Now if a new treatment came out that conferred a 30% survival benefit, and you didn't really know how to do it or deliver it, you would absolutely go ahead and educate yourself and learn about that. And so this is what you need to do if you identify a knowledge gap in your ability to talk about smoking cessation. There are loads of really good resources. The ISLAC webpage is a good place to start. You'll find some really good resources, and hopefully some local training as well that you can access. And, you know, there's difficulty about discussing smoking cessation with patients. Well, we all want happy and satisfied patients, right? We want patients that we're really engaged with, and if you can discuss smoking cessation in a positive and useful way, that actually increases patient satisfaction. We know that patients who smoke want to quit, they regret ever taking this up, and if you can have a meaningful discussion, then patients really appreciate that and they are crying out for help. So nicotine addiction is complex. We've heard there's a behavioral component. We know that there's a biological component. You don't have to be an expert in addiction to deliver something useful in the clinic, okay? We know from evidence-based medicine that it's that combination, right? Something that deals with the behavioral side, something that deals with the biological side, and combining those two things together gives patients the best chance of quitting. People who smoke and people with lung cancer face a lot of stigma and society really rains down stigma upon them. There's a really huge genetic component to initiation, maintenance, and quitting, okay? And I think this is an important message to give to your patients. This is not that, you know, you're unmotivated, you're lazy, you can't be bothered, or whatever. These are the kind of things that patients tell me that they hear from society all the time. A lot of this is to do with your genetics and what you're born with. So the model that I use, and there's lots of variations on this theme, but this is the shortest one and the simplest one that my brain can handle. It's ask, advise, and help, and repeat, okay? So this is a loop that we need to use each time. So ask all of our patients about smoking status and document this. And this is a chronic relapsing and remitting disease. This changes, this is dynamic. We may find that someone quits, and then a few months later they've relapsed and they've taken up smoking again. We may speak to someone who's not ready to quit at that point in time, but a few months later is. And we won't know this unless we ask. And we can ask some parameters around sort of level of nicotine dependency, and that can help somewhat, but to be honest, if you're facing a life-threatening diagnosis like lung cancer and you're smoking, that signifies a very high level of addiction and you're gonna throw everything at it. So I've never prescribed anything less than the highest amount of nicotine therapy, replacement therapy that I can. If they quit smoking, then reinforce this. Congratulate them. This is a huge milestone and a really important event. And that positive reinforcement is good. And people may need help with maintaining smoking cessation as well. So even though they may have quit, ask how they're going. Can you help? Is there anything that they're particularly struggling with? When we advise patients to quit, we need to really sort of tailor this and use language that's patient-centric, non-confrontational, and non-judgmental. And we can tailor this depending on where we're working. I, as a pulmonologist, may have a different sort of advice to give than a surgeon or a medical oncologist. So tailoring that advice to the patient and where they are on their particular journey is important. This is the key step, offering help. It's great to ask. We need to know that. It's great to advise. But this is the key step that's gonna help patients on their journey to quitting. So as I've said, it's the behavioral side of things. And I tend to use Quitline because it's very convenient, it's telephone-based. But if there are psychologists that you can refer to locally for people that may have other comorbidities, mental health illness in particular, then you can do that. And prescribing something. So that something is the doctor that I would do. And that's gonna be pharmacotherapy, generally combination nicotine replacement therapy, or Varenicline. They're about equal efficacy. So I don't really mind what the patient chooses. It's down to patient choice. They may prefer the idea of patches or pills. We've heard about this already. Smoking is a brilliant way of getting nicotine to the brain. You can see after one cigarette, there's 88% occupancy of the receptors. That leads to massive dopamine release, which leads to the sort of rewarding effects of smoking. And then as that dopamine level falls, that leads to the withdrawals and the cravings. And we can see here on this logarithmic scale, this spike here is nicotine delivery from a cigarette. And in comparison, we can see patch here and gum. The delivery here is low and slow. And it's really quite a different way of delivering nicotine. The remit really of nicotine replacement therapy and pharmacotherapy is to reduce the withdrawal symptoms and allow the sort of behavioral interventions to sort of act and the patient to reimagine their life without cigarettes. And so this is the sort of typical day in someone who smokes. They wake up in the morning with very low nicotine levels in the blood. They start smoking, aiming to get to a comfortable level of plasma nicotine, maintain that through the day, and then go to sleep and nicotine levels fall to their nadir and then wake up in the morning and it all starts again. And this is every day. So I think an informed patient is a knowledgeable patient. And hopefully that translates to better treatment effects and outcome as the patient really understands what we're trying to do and the rationale behind it. So I like to use some visual aids for this and combining those two graphs that I've just shown. And I draw this all the time on bits of paper for patients to explain what we're trying to do and so that they really understand. And so I'll say to them, this is where you sit at the moment. This is where you sit at the moment with your plasma concentration. And this is what we're gonna try and do with some nicotine replacement. Generally, we tend to underdose, but you may sit here. And the difference between where you're comfortable and where you are with nicotine replacement therapy represents the sort of withdrawals and cravings. So we need to try and move the nicotine replacement dose up towards where you're more comfortable and attenuate the withdrawal and craving effects. And so we can do this with a patch and we can add on some rapid acting formulations such as gum, and that may not be enough. And so you might need to have a double patch and you might need to add gum onto that. And we just titrate that and we work out what the dose is gonna be for you. And that could change over time, but we just want to make sure that you're comfortable and then you can focus more on the sort of behavioral side of things without having to deal with the cravings and the withdrawals. And so the patient chooses what they prefer and I'm writing a prescription. And if they've chosen combination NRT, then I like to use videos as well. So these are some great videos from Quitline in Australia. They're two minutes long, they're cartoons, they're very well done. And as I'm writing out the prescription, I put this on the computer and then the patient can watch the videos because there's so much confusion about how to use NRT and this runs the risk of treatment failure. And if the patient fails in their treatment, then this erodes faith in themselves, erodes faith in you, and it just makes that process of quitting even harder. And finally, as I've alluded to, smoking cessation is a team game with the patient at the center, but hopefully involving every single member of the MDT and involving primary care as well. So I write fairly kind of a detailed letter to the GP, not just to say that we've discussed smoking cessation, but this is what we've discussed and this is the plan that we've kind of come up with and this is what the patient's gonna do and please can you check and see how they're going and how we're gonna adjust treatment going forward. And then of course, when your patient comes back to the clinic in a few months time, it's ask, it's advise, and it's help. So in conclusion, we know that smoking cessation is really important for your patients. Use a simple model to help make sure that you cover all of those different components. Definitely be evidence-based. Update the gaps in your professional development. Keep the conversations very positive. Keep them patient-centered. Set some expectations from the beginning. This is not gonna be a quick and easy thing to do. This is gonna take a lot of effort from everybody and there's gonna be a whole team really supporting the patient at the center of this. Inform your patients and educate your patients and use visual aids, I think can help with that, and make talking about smoking and smoking cessation part of your routine every time. So, thank you very much.

Associate Professor Marshall

smoking cessation

lung cancer screening

team approach

nicotine replacement therapy