Prevention

Smoking Cessation Program

What We Do

We’re not here to judge. We just want to help.

Almost 25% of the patients who come to Siteman Cancer Center smoke cigarettes or use nicotine. This concerns us for a key reason: cancer patients who smoke don’t tolerate treatment as well and are less likely to recover.

Li Shiun Chen
Li-Shiun Chen, MD, MPH, ScD.

We understand that quitting smoking is difficult, and that you’ve probably tried to quit several times – maybe even more. If you’ve recently been diagnosed with cancer, you may be less inclined to quit than ever before. But if you can quit, your treatments will work better, and you’ll have a higher chance of survival.

The Smoking Cessation Program at Siteman Cancer Center, located at the Washington University School of Medicine in St. Louis and Barnes-Jewish Hospital, is here to help patients and non-patients alike quit smoking. We are a team of researchers and physicians from across the university community with expertise in smoking cessation treatment, smoking cessation guidelines, cancer prevention, lung cancer, implementation science, and information systems. Our goal is to equip you with expert advice and innovative resources so you can achieve a smoke-free life.

The Program is led by Li-Shiun Chen, MD, associate professor of psychiatry at the School of Medicine.

Adult Smoking Rate in Missouri

Smoking rates by state in the U.S.
According to this map, 20.1-23.7% of Missouri adults smoke.

 

23% of the patients at Siteman Cancer Center smoke. For comparison, the national smoking rate in the United States is about 15%. In Illinois, the rate is 16%, and in Missouri, it’s 22%.

It’s clear that smoking dramatically increases a person’s risk of cancer – not just lung cancer, but 14 additional types as well. It’s also clear that the rate of smoking in our state is dangerously high.

That’s why the Smoking Cessation Program has a two-fold mission: to help cancer patients quit smoking and to help others in our area quit as well.

How do we help?

If you come to Siteman Cancer Center with a history of smoking, you’ll benefit from our program in a number of ways. We’ve spearheaded several new initiatives to help patients, including:

  • Launching a text message program to give patients motivation and encouragement as they work to quit.
  • Ensuring that patients receive evidence-based smoking cessation treatment services, such as advice about quitting, FDA-approved medications, and referrals to telephone Quitlines, text, and app programs.
  • Customizing electronic record-keeping systems in the hospital to make sure that patients who smoke don’t fall through the cracks.
  • Implementing learning  health systems to provide patients with feedback as they work to quit and offer long-term support to those who have successfully stopped smoking.

Click here for more information about the smoking cessation tools available to our patients and members of our community.

Cancer Cessation Initiative

Our smoking cessation program is funded in part by the National Cancer Institute’s Cancer Moonshot. As part of the Moonshot, the NCI launched the Cancer Center Cessation Initiative, a targeted effort to help cancer patients quit smoking. Siteman is one of only 22 cancer centers nationwide to receive funds through the Cessation Initiative.

For more information about the Cancer Moonshot, click here.

Why Quit?

The research is clear: cancer patients who quit smoking have better outcomes than patients who don’t. Their treatments go more smoothly, and they have a greater chance of survival.

Still, it’s common for cancer patients who smoke to assume that there’s no point to quitting once a cancer diagnosis is in hand.  They believe that it’s too late: that the cigarettes have already given them cancer, and that quitting will not be worth the challenge that it brings.

But studies have shown that this is far from true. Quitting smoking is always good for your health, even – and especially – after you’ve been diagnosed with cancer.  It’s never too late to take charge of your addiction.

 

Dr. Chen And Patient
Li-Shiun Chen, MD, consults with a patient.

How will quitting help fight my cancer?

  • You will reduce the risk of your cancer progressing.
  • Your cancer may respond better to your treatment.
  • You may have fewer side effects from your treatment.

How will quitting help my surgery?

  • The earlier you quit before your surgery the better.
  • You will reduce your risk of wound problems or chest infections.

How will quitting help my treatment?

  • You will increase your ability to fight infection from chemotherapy.
  • You are  more likely to respond to chemotherapy.

How can I get more help?

  • Ask your care team about medication to help you cut down or quit.
  • Call 1-800-QUIT-NOW
  • Use a TEXT program (free)
  • Explore smokefree.gov
  • Download a free app, such as quitStart

Using Siteman’s text message program

Text one of the keywords below to 47848:

  • Text CRAVE if you need help beating a craving
  • Text MOOD if you need an emotional boost
  • Text SLIP if you need help getting back on track after you smoke
  • Text Siteman to set a quit date

 

Resources for Patients

The Siteman Cancer Center (SCC) is more than just surgeons, medical oncologists and radiation oncologists; we are nutritionists, social workers, and psycho-social supports and hire the best staff to operate with exceptional collective team competency. The team of doctors, surgeons, nurses, and support staff understands that fighting cancer is a journey and they care about your overall physical and mental health. Instead of just asking about tobacco smoking status, we are here to offer evidence-based treatment options. Quitting smoking is challenging. You are not alone. Good support and medication can increase your chances of quitting smoking successfully.

Medications to help quit smoking

While medication can’t make you quit smoking, it can sometimes help you cope with your cravings.

Medications used to treat nicotine addiction include:

  • Nicotine substitutes (such as a patch, gum, inhaler, or nasal spray)
  • Varenicline
  • Bupropion

For more detailed information o n medications, go to the drop-down menu at the top of the page and select “Medication Information for Providers.”

Accessing the medications you need

If you are concerned about obtaining insurance coverage for anti-smoking medications, there may be resources available to help you. Patients insured under Medicare, Medicaid, or SeniorCare should check their policies to see what drugs are covered.

If you do not have insurance, or have an inadequate policy, the following organizations may be able to assist:

Quit Guide

Cigarette Substitutes and Safety

Over the past few years, e-cigarettes have grown in popularity among adults and youth. You may be wondering if they’re safe to use, or if they could even help you beat your addiction to regular cigarettes. Combustible cigarette usage continues to decrease and e-cigarettes have grown in popularity among adults and youth. Many patients who smoke ask their physician about e-cigarettes.

Are e-cigarettes less harmful than regular cigarettes?

Technically, yes, but that still doesn’t mean they are safe. Though e-cigarette aerosol generally contains fewer toxic chemicals than smoke from regular cigarettes, it is not harmless. It can still contain dangerous substances.

Could e-cigarettes help me quit smoking?

Possibly, although there isn’t much evidence to suggest that such an approach would be successful. To quit smoking, it’s better to start by speaking with your doctor. He or she can suggest resources that would be more useful to you, such as telephone counseling via a quitline or even a medication.

If you do choose to smoke e-cigarettes, it’s important to make sure that you don’t end up amplifying your addiction to nicotine. Opt for e-liquids without flavors and either no or minimal nicotine. Work with your physician to develop a plan to eventually stop using all tobacco products, including e-cigarettes.

For more information, visit the CDC information page on e-cigarettes.

Additional information

Teens and Vaping

STL Moms: Teens and vaping hazards

E-cigarette usage associated with increased quit attempts and successful smoking cessation

Smoking cessation and electronic cigarettes in community mental health centers

Medication Information for Providers

Many providers are not aware that seven medications have officially been approved by the FDA to treat  nicotine addiction.

Medications available over the counter

Nicotine patch

Nicotine Patch

The nicotine patch seeks to thwart cigarette cravings by supplying the patient with nicotine through the skin. The patch typically transmits nicotine for a period of 16 to 24 hours. Patients are advised to use Nicotine patches for about 12 weeks.

Though the patch can be accessed over the counter, it can also be prescribed.

Nicotine gum

Nicotine gum provides the patient with nicotine while also offering a substitute – chewing – for the act of smoking. Some patients find this to be effective.

Patients may chew as many as 20 to 30 pieces of gum a day for six to eight weeks. The gum is available in 2 mg or 4 mg doses, depending on the severity of the patient’s nicotine addiction.

Nicotine lozenge

The nicotine lozenge offers a dose of nicotine in cough-drop form. Patients may choose between the 2 mg or 4 mg strengths, depending on their rate of nicotine consumption.

Lozenges should be taken for 8 to 12 weeks. Patients should take as many lozenges as they need each day, even up to 12.

Prescription medications

Varenicline

Varenicline

Varenicline makes it easier to quit smoking by diminishing a patient’s enjoyment of nicotine and preventing symptoms of withdrawal. Patients should start Varenicline seven days before quitting and continue taking it for about 12 weeks.

Side effects can include headache, nausea, and disturbed sleep.

Full Prescribing Guide

Nicotine spray

Nicotine Spray

This spray infuses a concentrated dose of nicotine into the body through the nose. Patients are advised to use one to two sprays an hour and to continue the spray for up to three months.

Package Insert

Bupropion

Bupropion is a pill that can help limit nicotine cravings. In some patients, it has also been shown to improve symptoms of depression. Patients may take Bupropion for seven to 12 weeks.

Package insert

Nicotine inhaler

Nicotine InhalerThis prescription medication is meant to simulate the experience of smoking a cigarette. The tube delivers a dose of nicotine when it is “puffed” by the patient. Patients typically use the inhaler for eight to 12 weeks.

Package Insert

Common questions and myths about medication

What medications are recommended by practice guidelines and approved by the FDA?

The approved medications include nicotine replacement agents (patch, lozenge, gum, inhaler, spray), bupropion, and varenicline.

Research suggests that the most effective course of medications is a combination of nicotine replacement or varenicline.

Is there a black box warning for varenicline? What are the indications?

Varenicline used to carry a black box warning for neuropsychiatric side effects, but this was lifted in 2016 after the EAGLES trial.

The added indications of varenicline are smoking reduction and smoking cessation.

Why might nicotine lozenges, patches, or gum fail? Should patients stop using these drugs if they relapse to smoking?

The patch can cause insomnia and skin irritation. Nicotine gum or lozenges may cause nausea.

If a patient relapses to smoking, he or she should continue to use the medication.

What are potential medication adjustments to make for smokers who have quit smoking?

Tobacco induces CYP1A2 activity. Smoking will lower levels of warfarin, opioid, clopidogrel, theophylline, and inhaled steroids. Consider reducing the patient’s dose of these medications if he or she quits smoking.

How often are smokers interested in receiving help for quitting or cutting down?

70% made an attempt to quit recently.

90% are interested in quitting or reducing their consumption of cigarettes.

How much earlier do smokers die compared to non-smokers?

Smokers tend to die 12 years earlier than non-smokers. However, this difference is reversible by quitting.

In-patient Support

The prevalence of smoking among patients entering the hospital remains much higher than in the general population, as individuals with chronic conditions that require hospitalization are more likely to smoke. Hospital settings present an opportune time to promote smoking cessation.

Why promote smoking cessation in the hospital?

Hospitalized patients who smoke frequently leave the floor for smoking breaks. This diminishes the quality of their care and creates a variety of problems for hospital staff. Research conducted at the Washington University School of Medicine and Barnes-Jewish Hospital has revealed the following:

  • Patients and staff members become susceptible to safety risks when patients leave the floor.
  • Critical assessments and medications can be missed when patients are absent for smoking breaks.
  • Valuable staff time is taken up when frail patients need assistance leaving the floor to smoke.

How to initiate smoking cessation

Patients are often asked about their smoking habits, but very rarely assisted with cessation. A survey of providers and patients revealed that the following strategies are a good place to start:

  • Asking directly: 86% of providers and 76% of patients want every patient who smokes to be asked if they want help.
  • Medication: 65% of providers and 67% of patients want every patient who smokes to be offered medication.
  • Advice: 62% of providers and 58% of patients want every patient who smokes to be offered brief advice to quit smoking.

Providing support

According to the 2008 United States Public Health Service guidelines for quitting smoking or chewing tobacco, patients are more likely to quit successfully when they are treated with counseling as well as medication. For more information about medications that can help patients, quit, select “Medication Information for Providers” on the drop-down menu at the top of the page.

Evidence-based support programs are also great tools for patients. It is important to offer positive, supportive, and non-judgmental support to patients and focus on boosting confidence and motivation to quit in patients who smoke.

Research

The Smoking Cessation Program at Siteman Cancer Center, located at the Washington University School of Medicine and Barnes-Jewish Hospital, is run by a community of clinicians and scientists who study nicotine addiction and smoking cessation methods.

Some of our major areas of research include the following:

Implementation of smoking cessation care in medical settings

Dr. Laura Bierut and patient
Laura Bierut, MD, speaks with a patient in her clinic.

We have developed a health system intervention for smoking cessation and shown that it is effective, yielding a 3-fold increase in patients’ receipt of smoking cessation evidence-based therapy (EBT) and a significant reduction in patient smoking rates over three years. We are also studying a smoking cessation implementation gap among patients with serious mental illness (SMI).

  • Chen LS, Baker TB, Korpecki J, Johnson K, Hook J, Brownson RC, Bierut LJ. Low-burden strategies to promote smoking cessation treatment among patients with serious mental illness. Psychiatric Service, 2018; 69(8):849-851. PMCID: PMC6280191.
  • Chen LS, Baker TB, Korpecki J, Johnson K, Hook J, Brownson, RC, Bierut LJ. Low-burden strategies to promote smoking cessation treatment in patients with serious mental illness. Missouri Coalition for Community Behavioral Healthcare Conference, Selected Symposium Presentation. Louis, Missouri. 2018.
  • Ramsey AT, Chen LS, Bierut, LJ. Optimizing a high-reach, light-touch approach to sustainable smoking cessation treatment across an academic healthcare system. Annual Conference on the Science of Dissemination and Implementation Washington, D.C, 2018.

Precision medicine and smoking cessation treatments

Our work has shown how genetic and environmental factors can inform personalized smoking cessation treatments. Specifically, we have identified that patient response to smoking cessation medications varies with genetic markers such as CHRNA5 or CYP2A6.

  • Salloum NC, Buchalter EL, Chanani S, Espejo G, Ismail MS, Laine RO, Nageeb M, Srivastava AB, Trapp N, Trillo L, Vance E, Wenzinger M, Hartz SM, David SP, Chen LS. From genes to treatments: A systematic review of the pharmacogenetics in smoking cessation. Pharmacogenomics. 2018; 19(10):861-871. PMCID: PMC6219447.
  • Chen LS, Baker TB, Jorenby D, Piper M, Saccone N, Johnson E, Breslau N, Hatsukami D, Carney RM, Bierut LJ. Genetic variation (CHRNA5), medication (combination nicotine replacement therapy vs. varenicline), and smoking cessation. Drug Alcohol Depend. 2015; 154:278-282. PMCID: PMC4537319.

The impact of genomics on clinical care and public health

We have established the utility of genetic markers for predicting delay in age of smoking cessation and acceleration in age of lung cancer diagnosis. We conducted a large, genetic meta-analysis to clarify the clinical and public health significance of a robust common genetic marker identified in genetic studies of nicotine dependence.

  • Chen LS, Baker TB, …, Bierut LJ. Genetic risk can be decreased: Quitting smoking decreases and delays lung cancer for smokers with high and low CHRNA5 risk genotypes – A Meta-analysis. Ebiomedicine. 2016; 11:219-226. PMCID: PMC5049934.
  • Chiu A, Hartz S, Smock N, Chen J, Qazi A, Onyeador J, Ramsey AT, Bierut LJ, Chen LS. Most Current Smokers Desire Genetic Susceptibility Testing and Genetically-Efficacious Medication. J Neuroimmune Pharmacol. 2018 Dec;13(4):430-437. doi: 10.1007/s11481-018-9818-1. Epub 2018 Oct 29. PMCID: PMC6245658.

Gene-environment interplay

We have identified how genetic and environmental risks jointly influence nicotine dependence and smoking cessation.

  • Chen LS, Baker TB, Piper ME, Smith SS, Gu C, Grucza RA, Smith GD, Munafo M, Bierut LJ. Interplay of genetic risk (CHRNA5) and environmental risk (partner smoking) on cigarette smoking reduction. Drug Alcohol Depend. 2014; 143:36-43. PMCID: PMC4161618.
  • Grucza RA, Johnson EO, Krueger RF, Breslau N, Saccone NL, Chen LS, Derringer J, Agrawal A, Lynskey M, Bierut LJ: Incorporating age at onset of smoking into genetic models for nicotine dependence: Evidence for interaction with multiple genes. Addiction Biology 15(3): 346-357, 2010. PMCID: PMC3085318.

Technology-based behavioral health tools

These tools have demonstrated effectiveness for a variety of health conditions as stand-alone interventions, partial replacements to clinician-delivered care, or extensions that supplement clinician-delivered care.

  • Ramsey, A. T., Satterfield, J., Gerke, D., & Proctor, E. (2019). Technology-based alcohol interventions in primary care: A systematic review. Journal of Medical Internet Research, 21(4). PMCID: PMC6475823
  • Cavazos-Rehg, P. A., Krauss, M. J., Costello, S. J., Ramsey, A. T., Petkas, D., Gunderson, S., Bierut, L. J., & Marsch, L. A. (2018). Delivering information about medication assisted treatment to individuals who misuse opioids through a mobile app: A pilot study. Journal of Public Health, 1-6.
  • Ramsey, A. T., Lord, S. E., Torrey, J., Marsch, L. A., & Lardiere, M. R. (2016). Paving the way to successful implementation: Identifying key barriers to use of technology-based behavioral health tools. Journal of Behavioral Health Services & Research, 43, 54-70. PMCID: PMC4362852

Smoking and mental health

We found that positive behavioral and psychological outcomes tend to accompany smoking cessation.

  • Cavazos-Rehg, P. A., Breslau, N., Hatsukami, D., Krauss, M. J., Spitznagel, E. L., Grucza, R. A., … & Bierut, L. J. (2014). Smoking cessation is associated with lower rates of mood/anxiety and alcohol use disorders. Psychol Med44(12), 2523-2535. PMID: 25055171

Updates

Smoking Cessation Program featured in St. Louis Magazine

A recent article in STLMag profiled the program for its success in expanding smoking cessation efforts among Siteman Cancer Center patients.

Twice as many Siteman patients assessed for smoking

In an article published on July 17 in the journal Translational Behavioral Medicine, investigators from the Smoking Cessation Program share the progress the program has made in screening cancer patients for nicotine addiction and offering assistance to quit.

Smoking cessation program receives prestigious national grant

The Smoking Cessation Program at Siteman Cancer Center has received $480,000 in funds from the NCI’s Cancer Center Cessation Initiative. A branch of the NCI’s Cancer Moonshot program, the Initiative seeks to reduce or eliminate smoking among cancer patients. Siteman’s program is one of only 22 nationwide to be chosen for the grant.