The Surgeon General’s warning against cigarette smoking was put on packs in 1965, and 50 years later, approximately 18% of Americans still smoke. Cigarettes cause almost all tobacco-related diseases and death, but lung cancer screening and smoking cessation programs can make an impact on these numbers and on patient’s lives, according to Nancy Sayegh-Rooney, RN, Pulmonary Nurse Navigator and Certified Tobacco Specialist Counselor at Richmond University Medical Center on Staten Island, NY.
“Can We Talk?”
The death rate due to cancer is higher on Staten Island than in New York City overall, and lung cancer is the number 1 cancer-related cause of death among both men and women in the community. Since 2014, when the lung cancer screening program was established at Richmond, over 300 patients have been screened, and early-stage lung cancer has been detected in numerous women with no symptoms. “That’s exciting—to make that difference in people’s lives,” she said at the 2017 Academy of Oncology Nurse & Patient Navigators (AONN+) West Coast Regional Meeting.
When members of the community come in for a patient assessment prior to a low-dose CT scan, she conducts about 30 minutes of smoking cessation counseling. “I ask ‘Can we talk’ about tobacco,” she said, adding that many people insist they have no interest in quitting and only showed up for the CT scan.
“How many years have we been telling patients, ‘You’ve got to quit smoking; you’ve got to lose weight’? It’s not working. We have to change the verbiage,” she said. “They don’t want to be judged; they know what they have to do. But by saying, ‘Can we talk,’ we give them the right to say ‘Yes’ or ‘No.’ It gives them some control.”
The Power of Nicotine
Nicotine causes addiction; it does not cause cancer. “But it’s a scary addiction, and it happens fast,” she said. When a person inhales a cigarette, nicotine reaches the brain within 7 seconds, and over 69 known carcinogens enter the body. Previously, it took 11 seconds for the nicotine in a cigarette to reach the brain, but Big Tobacco coated the tobacco leaves used in the cigarette to make them burn faster, she noted.
One cigarette contains 1 mg of nicotine, and nicotine has a 2-hour half-life. Within an hour, the smoker is left with 0.5 mg in the body and will begin to crave another cigarette. “We see all of the smokers taking smoke breaks at the same times during the day,” she noted. “They didn’t call or text each other. They’re all on the same withdrawal pattern.”
E-cigarettes have become pervasive. The product is heavily marketed toward young adults, and “no one knows what’s in that vapor,” she said. E-cigarettes are not regulated by the FDA, and since they are not considered tobacco, are not taxed. “When the prices eventually go up, what are these kids going to smoke?” she asked. “It’s a back door to get them hooked on nicotine.”
Tobacco dependency is a chronic condition, and a smoker will attempt to quit an average of 8 times before being successful. Every patient deserves access to treatment for tobacco dependency, she said, and healthcare systems should recognize the need for smoking cessation programs for patients and employees. She explained that these services are actually cost-effective for employers. If a smoker takes 3 smoke breaks a day, it adds up to 45 minutes per day away from work in addition to a lunch break. “This is killing employers,” she added.
Changing the Routine
Smoking is a psychologic and physical addiction, and each time a smoker lights up, he or she builds tolerance and dependency. “It’s their best friend; it’s part of who they are,” she said.
A myriad of factors might motivate a smoker to finally quit, including health issues, family (particularly grandchildren), the high cost of smoking, and vanity alone. Third-hand smoke is the residue on hair, skin, clothes, carpets, and surfaces inside homes. “It’s toxic, and cats and dogs can get lung cancer from it. That may be motivation enough for them to quit,” she said. “But bottom line, it has to be an “aha” moment. You can tell them to quit all you want, but they have to want it.”
Helping patients to reach their “aha” moment requires education, she said. Prescreening assessments offer a “teachable moment,” and when she conducts screenings, she begins the education process. She encourages them to avoid routines that trigger cravings. “If the phone triggers you in the kitchen, go into a different room,” she said. “If you get in the car and reach for a cigarette at Third Avenue, change your route.”
The price of a pack of cigarettes varies depending on the state, but the price of smoking can be prohibitive. “You have to visualize with them how much money they can save,” she said. “Tell them to get a Mason jar, put the cigarette money in there, and buy themselves, not their grandkids, something special as a reward. It’s something positive to keep them going.”
What If I Fail?
According to Ms Sayegh-Rooney, when smokers attempt to quit, their biggest fear is often failure. “I tell them if they smoke 1 less cigarette a day, they’re winning. And If they slip up, it’s okay, just put it out,” she said.
Smokers are different from other patients with cancer because of the stigma associated with smoking. With no other cancer is there a presumed amount of blame, eg, “You have lung cancer? I didn’t know you were a smoker.” Even providers can pass judgment on patients who smoke and have lung cancer, “but nobody deserves that,” she said.
Quitting also ignites fears of depression, irritability, and cravings, but nicotine replacement (eg, patches, gum, and lozenges) can alleviate or prevent these symptoms. “Nicotine replacement does work,” she said. Each cigarette contains 1 mg of nicotine, so a pack-a-day smoker should use the 21-mg patch, with the addition of gum or lozenges if cravings do not subside. However, it is necessary to know exactly how much a patient is smoking before recommending nicotine replacement, she warned. Too much nicotine will cause adverse effects, so treatment must be tailored accordingly. “You have to sit down with the patients, and they have to be honest with you. If they tell you they smoke half a pack, they probably smoke a pack,” she said. “They don’t want to be judged, but I tell them there’s no judgment here.” Patients who are pregnant or have had a myocardial infarction or arrhythmia should not use nicotine replacement, she noted, adding that the patch often causes vivid dreams and nightmares, so she instructs patients to take it off before going to bed.
The Power of Group Therapy
According to Ms Sayegh-Rooney, there’s power in numbers. She leads a 6-week smoking cessation class in the spring and fall that is free and open to the community. She sets an agenda for each week, and at the end of week 4, they set a quit date together. “It’s a countdown,” she said. “In the last 2 weeks before they quit, they have to prepare and clean the smell out of everything, get the house and car ready, and make sure they’re prepared for triggers.”
She stressed the importance of a “fire escape plan,” if coworkers or family members expect them to join them outside for a cigarette. “Go to the bathroom, wash the dishes, say you have to make a phone call,” she said. “In 2 minutes the craving is over, but they have to have a plan.”
A pack-a-day smoker spends about 2 hours of his or her day smoking, so it is vital to replace the time spent smoking with positive activities and distractions. She teaches the “5 D’s”: delay the first cigarette, distract, drink water, deep breathing, and discuss. “If they can delay the first cigarette by distracting themselves, by the end of the day they’ll have had 1 less cigarette.” Drinking water helps with cravings and helps flush nicotine out of the body; deep breathing can promote relaxation; and discussions with other patients provide a sense of camaraderie. “When they come in that first week, I tell them, ‘You’re not quitting tomorrow or next week. You’re getting ready,” she said. “Quitting is a journey.”
Ms Sayegh-Rooney underlined the importance of collaboration between navigators in setting up these kinds of programs, and added, “The networking and the power we all have and share is incredible.”
