Giving up cigarettes a huge challenge, even for lung cancer patients

November 15, 2018 | by Alison Shore

Joanne Nelson has a 40-year smoking history but a desire to give it up. What has been her biggest obstacle to quitting?
“Doing things for the very first time without a cigarette,” she said. “Smoking is something that’s been with me almost my whole life — through good times, anger, joy and stress. It’s also something that shut me up — instead of speaking out, I’d grab a cigarette.”
Joanne has made several half-hearted attempts to quit on her own, always succumbing to the thinking that smoking was her one vice, and so be it. In the spring of 2017, she decided to look for a support group to help her quit — she found one at City of Hope.
Personal tragedies — including the sucide of her husband and the loss of her stepdaughter and her mother-in-law to cancer — were all addressed by City of Hope's Smoking Cessation Program. Joanne says that without the group's support, she would never have done so well. Through weekly group meetings, she became more committed and more confident, using tools, information and support offered by the group.
The program was designed and implemented in 2013 by Brian Tiep, M.D., director of the Pulmonary Rehabilitation Program and Smoking Cessation Program at City of Hope, whose fervor in confronting the ills of smoking is rivaled only by his compassionate understanding of the complexities of quitting. “It is not a character flaw to smoke,” Tiep emphasized. “It was a bad decision at some point in people’s lives, and then they became hooked.”
Tiep’s involvement with City of Hope began in 1972, when he arrived on a pulmonary fellowship and helped to implement a pulmonary rehabilitation program, one of the first in the region. He and his team left in 1986 to pursue other avenues of pulmonary rehabilitation.
Returning 20 years later, Tiep concluded that any meaningful therapy for patients with lung cancer or chronic obstructive pulmonary disease should include a smoking-cessation component. He relies on the invaluable support of Sophia Yeung, the Lung Cancer Screening Program administrative coordinator, and Jonjon Macalintal, D.N.P., to combat what he calls “the killer addiction” of smoking, one that he believes is more addictive for some people than heroin. He labels smoking “a chronic relapsing medical disease of the brain.”
Tiep advocates a two-pronged approach in the program: medication (varenicline), which simulates the desired effects of nicotine; and nicotine-replacement therapies (such as a patch, lozenge or chewing gum) combined with behavioral therapy (which includes weekly support group meetings). In his experience, medication alone produces a 25 to 30 percent success rate in quitting; the combined approach yields a 36 percent success rate. Generally, repeated attempts are required for success.

Screening Saves Lives

City of Hope’s program also includes a feature that proved to be lifesaving for Joanne: the recommendation for people aged 55 and older to obtain a computed tomography (CT) scan of the chest to screen for lung cancer (many of the people entering the Smoking Cessation Program already have a cancer diagnosis and realize quitting must be a part of their therapy). Joanne's first scan was negative; the second, six months later, revealed a spot on her lung. The results of a biopsy showed that she had stage 1 large cell lung cancer.
City of Hope’s Dan Raz, M.D., M.A.S., co-director of the Lung Cancer and Thoracic Oncology Program, used robotic surgery to remove the right upper lobe of Joanne's lung, as well as 17 lymph nodes, all of which were cancer-free. She required no chemotherapy or radiation therapy.
Because Dr. Tiep and City of Hope educated me about the importance of getting the CT scan, Dr. Raz was able to catch my cancer early,” Joanne said. “They saved my life.”
Lung cancer remains the leading cause of cancer-related deaths worldwide. According to the Centers for Disease Control, the rate of cigarette smoking in the United States has dropped to 15 percent (down from nearly 21 percent in 2005), but smoking accounts for the majority (80 to 90 percent) of lung cancer cases.

Not an Easy Walk

A conversation about smoking cessation should also address the issue of smoking initiation, said Tiep. Cigarettes contain 7,300 chemicals (70 of them known carcinogens) and they are designed to addict. Much of the chemistry of addiction occurs in the midbrain, where habits develop; if a brain is not fully formed, such as that of a teenager, triggering and locking in addiction are easier. Tiep said the tobacco industry knows this and targets teens in advertising. “They need to,” he said, “because the older smokers die.”
Joanne acknowledged that she started smoking in her teens. A stressful move from Canada to Los Angeles when she was 15 led to some defiance, and smoking was part of it.
Tiep’s concern about teenage targeting extends to e-cigarettes, the use of which he discourages for not only kids, but adults who are trying to quit conventional cigarette smoking. “Kids who use e-cigarettes are more likely to start smoking, and some of the e-cigarettes may have more nicotine than conventional cigarettes.” The stance that e-cigarettes can be a “healthier” path to quitting vexes Tiep, too. “The flavorings have chemicals, some of which are toxic. E-cigarettes may be less harmful, but they’re not harmless, and I do not consider them a good development. We just don’t know enough.”
What he does know is that Joanne has begun smoking again — four cigarettes a day — after being smoke-free for 50 days (and despite her lung cancer diagnosis). He says her case highlights the highly addictive nature of smoking and the frequent need for numerous attempts to quit. His support for Joanne and anyone trying to quit is unwavering. “Joanne is quite convinced it will happen. She’s struggling and we’re there to help her in whatever way we can.”
“This is not an easy walk,” Joanne stressed, “and it takes multiple efforts. I’m not there yet, but I want to be. My goal is still the same: zero cigarettes.”
On Nov. 15, City of Hope will partner with the American Cancer Society to promote the Great American Smokeout. Visit the booth on the Duarte, California, campus, where you can get information about lung cancer screening, smoking cessation and general cancer prevention.

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