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On oncology wards, busy clinicians are often burdened by time pressure and competing demands and may struggle to implement the 5As (Ask, Advise, Assess, Assist, Arrange) or ABC (Assess, Brief, Counsel) models for smoking cessation. However, despite various suggested models of care, implementation of cessation programs after a cancer diagnosis has been poor, with its management frequently perceived as being “out of scope” to core clinical care. But since the 2014 US Surgeon General’s (SG) report on smoking cessation, there has been increasing recognition that it is vital for improving patient outcomes.
Putting a number on survival
In our recent paper, we calculated survival benefits of smoking cessation among cancer types with five-year overall survival ranging from 10% to 90% using evidence from 23 studies published since the 2014 US SG’s report on smoking cessation and cancer. Among them was the largest cohort to date of 32 000 patients with various cancers from Japan. Our paper simplifies and addresses some of the variation inherent in small-scale studies.
Since publication, we have had positive feedback from peers that this is helping to fill a long-standing gap in clinical communication. Patients and clinicians now “have a number” to guide conversations and planning around cessation. This “number” (or rather, our working estimate) also provides a system-wide perspective of overall gains. For example, taking an Australian average five-year cancer survival of 71.5%, patients who quit smoking, gain a median survival of about a year, which is on par with other adjuvant treatments. Having said that, smoking cessation should never be regarded as a trade-off to standard treatment.
While our research has limitations — survival estimate varies widely depending on the cancer type, smoking history, and treatment received — the message is clear and remains the same: quitting smoking after a cancer diagnosis can make a difference. And it is never too late to quit.
A simple, scalable solution
Until smoking cessation is incorporated in routine cancer care, we propose the minimum standard of care should include the following:
- smoking status recorded accurately in the electronic medical record at patient entry; and
- a programmable automatic referral to smoking cessation support included in discharge summaries for patients identified as current smokers.
This low-cost, low-effort strategy is not only scalable, but can generate meaningful system-level data. We are aware that more conversations around smoking cessation are taking place in cancer clinics and other hospital settings, but the data are obscured in several places in NSW hospital data systems, “in the notes” or not recorded at all. Currently, information on cessation practices and system performance can only be obtained via expensive surveys of patient interviews.
Such a model of automatic, minimal intervention would present a rapid and practical response in low-resourced hospitals where intensive treatment for smoking is not perceived as the first-order priority. An opt-out strategy in which patients are automatically provided with smoking cessation support has been demonstrated to be effective in patients with cancer.
What can general practitioners (GPs) do?
GPs are intimately involved in a cancer patient’s journey, from identification of symptoms, diagnosis and post-discharge care. The Royal Australian College of General Practitioners recommends all professionals routinely identify people who smoke and offer them advice and cessation treatment at every opportunity. They also recommend smoking and vaping status be collected from age 10 years onwards. We are hoping that our paper will enable a more accurate assessment of their patient’s smoking status and enable a conversation around cessation to improve survival outcomes.
Evidence suggests that quitting within six months of a diagnosis provides the greatest benefits. GPs can play a pivotal role in these critical months. Identifying patients who are eligible for lung cancer screening, typically those who have smoked long term, is another opportunity to initiate conversations around quitting before the onset of symptoms.
Quitline remains an essential referral option, but it is worth noting that patients may be more receptive if they were opted in rather than being cold called.
We need a system, not just champions
Ultimately, supporting patients to quit smoking should not rely solely on the willingness of busy clinicians or the availability of specialist services. A systems-wide approach that combines automatic key steps, such as status recording and referrals, with supports like Quitline or GP guidance ensures all patients, not just those with cancer, benefit from smoking cessation interventions.
Dr Nouhad El-Haddad is a public health researcher at the UNSW International Centre for Future Health Systems at the University of New South Wales.
Professor Geoff Delaney AM, FRANZCR is a senior radiation oncologist at Liverpool Hospital, Lead of the Cancer Clinical Academic Group for SPHERE and Professor of Radiation Oncology, UNSW. He is a clinician researcher in cancer health services delivery, models of care and equity.
Professor Shalini Vinod is a senior academic radiation oncologist who specialises in the treatment of patients with lung and breast cancer. She leads the Lung Cancer Multidisciplinary Team at Liverpool and Macarthur Cancer Therapy Centres in South West Sydney.
Associate Professor Freddy Sitas is an epidemiologist with special interest in quantifying the effects of smoking and e-cigarette use and cessation. He is currently Chief Operations Officer at the UNSW International Centre for Future Health Systems and Adjunct Associate Professor in the School of Population Health at University of New South Wales.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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