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From a simple sore throat or laryngitis to cancers of the head and neck, including oropharyngeal, laryngeal, esophageal, and pharyngeal, smoking tobacco causes many problems for patients, and their otolaryngologists are in a good position to help them quit.
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February 2016Tobacco smoking is an important risk factor for head and neck cancers, and smoking cigarettes increases the risk of head and neck cancer 15-fold, according to the American Academy of Otolaryngology-Head and Neck Surgery. Even if a patient’s internist or general practitioner has already made the recommendation to quit cigarettes or offered tips for smoking cessation, an otolaryngologist can highlight that message. He or she can also emphasize the potential harms of smoking as it pertains to the ear, nose, and throat, as well as reinforcing the systemic consequences a patient’s other physicians have discussed.
“We all have to remind our patients that they need to stop smoking instead of just taking a history and accepting tobacco use,” said Stacey Ishman, MD, MPH, associate professor of otolaryngology-head and neck surgery at the University of Cincinnati and surgical director of the university’s Upper Airway Center. Dr. Ishman co-authored a 2015 review that found that the majority of studies on secondhand smoke and sleep-disordered breathing indicated a significant association between the two (Laryngoscope. 2015;125:241-247). “The act of mentioning the need to stop smoking as a critical health priority for our patients can make a significant difference, and the more providers who highlight the need to stop smoking, the better,” she said.
Expect to Meet With Resistance
Michael Vick, MD, an otolaryngologist with Wellstar ENT in Marietta, Ga., said that, initially, he gently admonishes his patients who smoke, making sure they are aware of the risks associated with their habit. “The majority are quick to admit that they know it is harmful,” he said, “but most are surprisingly reluctant to quit.” Some of Dr. Vick’s patients say they have tried and failed at previous attempts to quit, while some have been successful at cessation but ultimately “fall off the wagon,” and approximately 2% to 3% are willing to try something to quit. The vast majority, however, are unwilling to stop.
“What is most surprising to me and many colleagues that have reported similar stories are the patients who have been cured of their cancer through surgery, chemo, radiation therapy, or both, who have had major resections including laryngectomies, but still find ways—sometimes creative ways—to continue to smoke,” he said. “It is baffling, but it just goes to show the powerful addictive effect that cigarettes have on our population.”
It’s Not Just Cancer
Rahmatullah Rahmati, MD, assistant professor of otolaryngology-head and neck surgery at New York Presbyterian/Columbia and the medical director of the Adult ENT Clinic at the New York-Presbyterian Vanderbilt Clinic, says that most of his patients with head and neck cancers are either current smokers or have a past history of smoking. He added that smokers who do not have cancer may suffer from ear pain, pressure, infections in the setting of the Eustachian tube, nasal congestion and sinusitis, hoarseness, globus sensation, increased phlegm, difficulty swallowing, and throat pain, as well as laryngopharyngeal reflux disease.
An otolaryngologist can make the connection for the patient that smoking exacerbates all of these conditions. In a best practice paper on the controversy surrounding electronic nicotine device systems (ENDS), Dr. Rahmati and his co-authors wrote, “As physicians primarily involved in the treatment of head and neck malignancies, otolaryngologists have a particular responsibility in guiding patients toward effective methods of tobacco cessation” (Laryngoscope. 2015;125:785-787).
What Works Best?
Smoking cessation largely depends on the efforts and motivation of the patient trying to quit, and there’s no one-size-fits-all approach to helping a patient stop smoking. Practice guidelines suggest practitioners should use the Five A’s: Ask, Assess, Assist, Advise, Arrange.
Follow-ups with a patient who is trying to quit may not happen, because healthcare providers may feel overwhelmed dealing with complex patient populations with medical comorbidities or lower socioeconomic status, said Carla Berg, PhD, associate director of population sciences at Winship Cancer Institute of Emory University in Atlanta and associate professor in the department of behavioral sciences and health education at Emory’s Rollins School of Public Health in Atlanta. “But smoking cessation should be high on the list for all practitioners—and particularly for otolaryngologists. It’s still the number one killer of people in the U.S., and the number two globally,” she added. “We haven’t won the battle just because smoking has gone down.”
Available Methods and Medications
“Most smokers don’t want to stop smoking, or they can come up with a lot of reasons why they don’t want to quit,” said Dr. Berg. There are services and medications that increase a smoker’s odds of success, however.
State-funded quitlines—telephone-based tobacco cessation services—can be very effective. They are free of charge and apply motivational interviewing techniques during which smoking cessation counselors know how to handle a patient’s resistance. “The more convenient you can make them for people, the more likely people are to use the quitline,” said Dr. Berg. In some states, physicians send referrals to have quitlines reach out to their patients who smoke. “If the quitline proactively reaches out to the individual, that removes a lot of barriers,” Dr. Berg said.
Behavioral intervention used in combination with medication increases the odds of successful smoking cessation. Medications for those over the age of 18 include over-the-counter nicotine replacement products such as transdermal nicotine patches, gum, and lozenges, as well as prescription nicotine replacement products such as nasal sprays and oral inhalers. Non-nicotine prescription products include varenicline tartrate and buproprion hydrochloride.
Both the American Cancer Society and the National Cancer Institute have apps based on behavior change theories, according to Dr. Berg, and some medical practices have staff that have been trained in smoking cessation programs such as the one run by the Mayo Clinic for physicians, nurses, and other healthcare professionals.
Treatment Programs
While some patients are able to quit cold turkey and others do better with the assistance of quitlines, counseling, and/or medication, some patients require the additional support of smoking cessation treatment programs. The Mayo Clinic Nicotine Dependence Center (NDC), in Rochester, Minn., has treated more than 55,000 tobacco users as outpatients, hospital inpatients, or patients in their residential treatment program for tobacco. A 2009 paper on treating tobacco dependence in a medical setting found that for patients at the NDC who received outpatient services, the six-month smoking abstinence rates were reported to range from 22% to 25% (CA Cancer J Clin. 2009;59:314-326). The six-month smoking abstinence rate from hospitalized smokers who received counseling was 32%, and the one-year smoking abstinence rate for patients who entered Mayo Clinic’s residential treatment program was reported to be 52%. A 2011 study found that those who received residential treatment for tobacco dependence had significantly greater odds of six-month smoking abstinence compared with outpatient treatment among smokers in a referral clinic setting (Mayo Clin Proc. 2011;86:203-209).
Other nicotine treatment programs that include individual and group counseling, medications to relieve withdrawal, nutrition counseling, exercise classes, and stress management techniques are Serenity Vista Addiction Recovery Retreat in Boquete, Chiriqui, Panama, Smoking Cessation Wellness Spa Retreat in Tampa Bay, Fla., and St. Helena Center for Health in St. Helena, Calif.
Be Supportive and/or Use Scare Tactics, But Try Not to Judge
Physicians who have never smoked themselves, or who smoked briefly but never became addicted, may find it frustrating to treat seriously ill patients who continue to smoke. Mark W. El-Deiry, MD, FACS, chief of head and neck surgery at Emory University School of Medicine, said both of his grandparents smoked until they passed away and suffered from smoking-related complications, including heart disease and gastrointestinal disease.
“They were both terrific people and I loved them very much,” says Dr. El-Deiry, who has written about smoking and cancer of the larynx. “People who are not addicted to tobacco and nicotine often don’t understand the stranglehold it can place on patients and loved ones, nor the incredible difficulty in quitting.”
Opening the dialogue in a nonjudgmental but direct manner with patients is best, said Michael V. Burke, EdD, treatment program coordinator at the NDC. Emphasize the value of treating tobacco dependence using methods similar to those used for a chronic medical condition, and then either provide medication and counseling support or refer the patient for specialist care.
“Most patients do not realize that medications and counseling can dramatically increase their likelihood for success, and there is a dose-response relationship so that more/longer medications and longer-term counseling are more effective than shorter doses of either,” said Dr. Burke. “Otolaryngologists have an important teachable moment to address this.”
Renee Barcher is a freelance medical writer based in Louisiana.
The Five A’s
Carla Berg, PhD, associate director of population sciences at Winship Cancer Institute of Emory University in Atlanta and associate professor in the department of behavioral sciences and health education at Emory’s Rollins School of Public Health, has written extensively about smoking cessation and smoking behavior. She says the “five A’s” are very important for otolaryngologists to practice with their patients:
- Ask all patients if they smoke.
- Assess their motivation to quit and find out whether they have made recent attempts to stop smoking. Ask questions such as, “For what reasons might you want to quit smoking?” and, “If you’re not willing to quit, would you be willing to cut down?”
- Advise patients to quit smoking. While this sounds simple enough, some physicians may be so rushed for time that they overlook this step. “Brief advice from healthcare workers has been shown to have a big impact,” Dr. Berg said.
- Assist them. Have brochures in your office about smoking cessation and the number of a quitline available to hand out. Talk with patients about nicotine replacement or medications such as Zyban or Chantix.
- Arrange to follow up. “Accountability is a big factor in helping people who are quitting. Knowing your doctor is paying attention increases the urgency, and people think, ‘Oh, wow, that really is a big deal if my doctor is this concerned about it.’”
Smoking Cessation Medications
Nicotine replacement products (skin patches, gum, lozenges)
Buproprion hydrochloride (Zyban)
Varenicline tartrate (Chantix)
Clonidine
Nortriptyline
Source: National Institutes of Health
To Vape or Not to Vape?
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Dr. Rahmati, MD, assistant professor of otolaryngology-head and neck surgery at New York Presbyterian/Columbia and one of the authors of the policy statement, does not recommend e-cigarettes to his patients. “There’s not enough data to support their effectiveness in smoking cessation,” he added, “and, equally important, we don’t know the potential long-term side effects.”
Key policy recommendations from the statement support regulation of ENDS at the federal, state, and local levels, required registration with the FDA for ENDS manufacturers, warning labels on products and advertisements for ENDS, and prohibition of ENDS use where cigarette smoking is not allowed, as well as a ban on the marketing of ENDS to youth and of ENDS flavors that might appeal to children.
Additionally, new research out of the University of California San Diego says smokers who try e-cigarettes to help them quit may in fact be less likely to quit (Am J Public Health. 2015;105:1213-1219). Smokers in the study who had tried e-cigarettes were found to be half as likely to cut back on cigarette use and 59% less likely to quit. While the study’s author says more studies are needed, one possible reason for the findings is that smokers using e-cigarettes may be receiving an increase in nicotine over those not using e-cigarettes.