Tobacco cessation as a first-line cancer treatment – good for patients and the health system

What is the Action Framework? Who is it for?

The Pan-Canadian Action Framework for Implementing Smoking Cessation in Cancer Care lays out a simple and systematic way to implement smoking cessation programs in cancer centres. The document was created for those who oversee cancer centres across Canada including provincial and territorial governments, cancer agencies, healthcare administrators, and healthcare providers. Its purpose is to make it as easy as possible for these groups to work together in creating effective smoking cessation programs that use a combination of behavioural counselling, pharmacotherapy and follow-up/relapse support. The goal of the Action Framework is to work towards a future where every person with cancer across the country receives support to quit smoking for the best treatment and quality of life.

Why do cancer centres need smoking cessation programs?

The evidence is clear that if you have cancer, quitting smoking prior to your treatment will improve your outcomes. This applies to all cancer treatments including chemotherapy, radiation therapy and surgery. Being smoke-free also minimizes side effects and other complications following treatment. Because of this, in addition to improved patient health outcomes, smoking cessation support in cancer centres also plays a critical role in improving economic outcomes of the cancer system. Recent evidence shows that quitting smoking prior to treatment reduces cancer mortality rates by up to 30-40 per cent¹, and simulations also show that there is $50-$74 million in cost savings for every five per cent of cancer patients that quit smoking.² These cost savings come from healthcare providers being able to: practice more efficient medicine, decrease the time spent re-administering medicines, avoid having to perform additional surgeries, and the cost of additional drugs such as rounds of chemotherapy.

In addition to the evidence-based benefits for both patients and the health system, having these cessation programs in cancer centres will help in the collective push to achieving one of the priorities of the Canadian Strategy for Cancer Control (2019-2029). The Canadian Partnership Against Cancer (the Partnership) is the steward of the Strategy and working with provinces and territories to make changes to the cancer system and ensure all people with the disease have access to high-quality, sustainable treatment and care. The Action Framework will help the Strategy’s specific action to increase efforts to promote tobacco cessation and avoidance among cancer patients, and working with First Nations, Inuit and Métis to develop appropriate tobacco cessation approaches.

Why was the Action Framework developed?

Despite the strong evidence showing the benefits of quitting smoking, roughly one in five people in Canada continue to smoke after a cancer diagnosis. In addition, many cancer centres in Canada are still not providing on-site cessation support. There are many reasons for this. First, oncologists and others working in cancer centres tend to focus on the most immediate concern at hand, which is treating the cancer. Smoking cessation for a patient can fall by the wayside. Also, many cancer care providers are simply not aware of the impact that quitting smoking can have on treatment outcomes and view it instead as an optional support. Another reason for the absence of these programs in cancer centres is that, unfortunately, we’re seeing that there is still a stigma around smoking and cancer. Many in the health system think that smokers brought the disease upon themselves due to their lifestyle decisions, and this may lessen the cessation support they receive when they enter the cancer system. But with growing evidence, we’re seeing that it’s never too late for someone to quit smoking and doing so can have significant benefits to their treatment and the health system more broadly. The Action Framework is looking to change this gap in the system by providing step-by-step program-level guidance for cancer centre administrators to implement a comprehensive, evidence-based smoking cessation program and see that all patients with cancer are supported to quit smoking, right from the moment of diagnosis.

Smoking cessation supports are already provided in all provinces and territories, wouldn’t having them in the cancer centre be redundant?

It’s true that many programs already exist to help Canadians quit smoking, but these programs can often take months to see results. For someone with cancer who smokes, there is an urgency to quitting, as it’s ideal for them to quit at least two weeks prior to receiving treatment for maximum impact. As such, the smoking cessation support for people with cancer should be provided, ideally, at the time of diagnosis. The ideal scenario is that in their first visit to their oncologist, patients are screened for tobacco use and if they are a smoker, they are advised of the benefits of quitting and then referred onto an internal tobacco cessation program and counsellor. The most effective approach is creating a seamless process to connect patients with support to quit smoking as a part of their full cancer treatment plan.

Will these new smoking cessation programs be a financial burden?

Creating smoking cessation programs in cancer centres will require investment to get started but their economic benefits down the road will significantly outweigh the costs. For example, initial colorectal cancer treatment costs the health system around $28,000.³ Smoking reduces the effectiveness of treatment, sometimes resulting in recurrence which requires the patient to go through further treatment. The most comprehensive tobacco cessation support plan, which includes one-on-one counselling, nicotine replacement therapies, pharmacotherapies and follow-up supports would cost only $5,300.³

If the program is successful and a patient can quit smoking, it can yield big savings in the health system, as additional cancer treatments might not be required.

Our simulations show us that if you implement smoking cessation at the front end of the cancer experience for patients, the cost-savings down the road will be in the millions.²

What are the next steps with the Action Framework?

The Partnership has led the establishment of the Pan-Canadian Tobacco Cessation and Cancer Care Network. This network is made up of representatives from both tobacco control and cancer control in every province and territory, and it has led implementation of on-site smoking cessation programs in many Canadian cancer centres. This includes the BC Cancer Centre, whose program has seen considerable success in helping patients quit smoking and ultimately reducing system resources related to additional cancer treatments. But more work is needed to reach our goal of 100 per cent of ambulatory cancer centres offering smoking cessation programs by 2022. These efforts are right now focused on getting the Action Framework in front of those who set policy and quality care direction at cancer centres across the country.

What are your personal views on the Action Framework?

I think Canada has made great strides in communicating the harms of smoking and enacting policies that restrict access and accessibility of smoking. As a result, we’re seeing that the rates of daily smokers continue to decline amongst the general population. But I see that gaps continue to exist in helping reduce smoking in the cancer patient population. This needs to change. To support a patient to stop smoking once they are in the cancer system would have a profound impact on their treatment outcomes and can drastically reduce the use of health system resources, if done properly. We need to go back to the basics where we know if a patient stops smoking at the time of their cancer diagnosis, they will live longer and better, with a greater chance of cancer not returning. Apart from the human impact, if you are a policy maker, smoking cessation programs can also be an effective medicine for the economic health of the cancer system.

Dr. Renelle Myers is a thoracic respirologist at Vancouver Coastal Health and an Associate Professor at the University of British Columbia. She led the development of the Pan-Canadian Action Framework for Implementing Smoking Cessation in Cancer Care

References
1- Toll BA, Brandon TH, Gritz ER, et al. Assessing tobacco use by cancer patients and facilitating cessation: an American Association for Cancer Research policy statement. Clin Cancer Res 2013;19:1941-8. 10.1158/1078-0432.CCR-13-0666
2- Iragorri, N., Essue, B., Timmings, C., Keen, D., Bryant, H., & Warren, G. (2019). The cost of failed first-line cancer treatment due to continued smoking in Canada. In review.
3- Canadian Partnership Against Cancer. Key cost estimates on cancer treatment and smoking cessation in Canada. 2017. Available at: partnershipagainstcancer.ca/topics/key-costs-cancer-treatment-smoking-cessation-canada/