It is well established that for patients with cancer and cancer survivors, smoking cessation can significantly reduce mortality and improve their prognosis. However, nearly two-thirds of all people who smoke who develop cancer are unable to fully quit after being advised to do so, leaving both patients and providers frustrated and searching for more effective long-term methods.

The Duke Cancer Institute’s Smoking Cessation Program takes an individualized, intensive approach to helping patients who smoke to navigate the difficult journey toward nicotine abstinence. With expertise in both medical and behavioral health approaches and addressing disparities in tobacco use treatment in different populations, the program uses an algorithmic approach to combination nicotine replacement and has helped thousands of people to overcome their tobacco dependence.

One of the ways in which Duke helps patients at the practice level to effectively stop smoking is through adaptive pharmacotherapy treatment, which involves changing the medication or adding a second medication in the pre-quit period for patients who do not respond to the initial treatment of a nicotine replacement, such as Varenicline or a nicotine patch.

For many years, the best practice was to start a patient on a medication around their chosen quit day, when they go into withdrawal, says James Davis, MD, director of the Duke Smoking Cessation Program at Duke Cancer Institute. In the past decade, though, the shift has been to begin pre-quit treatment beginning one month before their quit day, which for some can show a dramatic response in reducing the number of daily cigarettes they smoke.

“In the world of smoking cessation, adaptive treatment really didn't exist like it does in other medical specialties. There were no data to support the idea of testing whether the medication worked first before having a patient try to quit,” Davis explains. “But adaptive treatment is a game-changer in smoking cessation; what we’re seeing now is that the people who show a response to medication ahead of their quit day are six times as successful in achieving long-term cessation.”

In a recent randomized control trial on adaptive treatment led by Davis, participants who expressed the desire to quit smoking but who still smoked at least five cigarettes a day were allowed to choose one of two common smoking cessation pharmacotherapies. While the full results will be published early next year, Davis says that initial findings show those provided with adaptive treatment had significantly higher 30-day abstinence rates than those who were provided standard treatment.

“This study takes the idea of adaptive treatment, which had really just been studied in a rigid research environment in the context of smoking cessation, and moves it into a real-world setting, where we have more of a collaborative interaction with patients about the medications and their side effects,” Davis says. “The results will show that patients can start pre-quit treatment on different drugs, but what’s important to the success of smoking cessation is the principle of adaptation.”

Having a better understanding of long-term treatment options for smoking cessation is especially relevant for patients with cancer and cancer survivors, says Jillian Dirkes, MSW, LCSW, program manager for the Duke Smoking Cessation Program at Duke Cancer Institute. “We usually keep patients in these populations on treatment for six to 12 months because we know that typically they’re more physically addicted and have a higher chance of relapse because the stress level is so high,” she explains.

While in the Duke Smoking Cessation Program, patients benefit from the team of oncology specialists with expertise in managing the medical and psychological issues that come with cancer treatment. In addition, a dedicated licensed clinical social worker continually checks in with patients frequently to address the behavioral effects of addiction during and after their treatment period.

Duke’s support services are robust and intensive to manage the kind of challenges that come up for patients with cancer who are trying to quit smoking, says Davis, noting the importance of continuous follow up. “If you're going to ask a person who's undergoing cancer treatment to quit, you’d better be able to provide them with substantial support month after month, week after week, both psychologically and pharmacologically.”

To provide the best outcomes for patients who are ready to quit smoking, Davis encourages clinicians to practice motivational interviewing, a topic that is covered extensively in the Duke-UNC Tobacco Treatment Specialist Training Program offered virtually throughout the year.

“Although we as providers are so concerned about health outcomes, individuals who smoke tend to be focused on much more proximal outcomes that will impact their lives much more quickly, such as saving money to be able to pay rent,” he says. “We need to realign ourselves as health care providers to support our patient’s own motivational basis for cessation.”