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Ann Thorac Surg 2010;89:926-930. doi:10.1016/j.athoracsur.2009.12.046
© 2010 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

A Thoracic Surgeon–Directed Tobacco Cessation Intervention

Benjamin D. Kozower, MD, MPHa,*, Christine L. Lau, MDa, Jennifer V. Phillips, RNa, Sandra G. Burks, RNa, David R. Jones, MDa, George J. Stukenborg, PhDb

a Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
b Department of Public Health Sciences, University of Virginia Health System, Charlottesville, Virginia

Accepted for publication December 17, 2009.

* Address correspondence to Dr Kozower, University of Virginia Health System, General Thoracic Surgery, PO Box 800679, Charlottesville, VA 22908-0679 (Email: bdk8g{at}virginia.edu).

Presented at the Fifty-sixth Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 4–7, 2009.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 
Background: Thoracic surgeons receive little training in promoting tobacco cessation despite the impact of tobacco use on their patients. There are only a few prospective reports of tobacco cessation efforts involving thoracic surgeons in the scientific literature. The purpose of this study was to prospectively evaluate a brief tobacco cessation intervention offered by surgeons in an outpatient thoracic surgery clinic.

Methods: Adult smokers from a single-institution thoracic surgery clinic were enrolled in a single-arm prospective pilot trial between January and December 2008. Patients received a 10-minute intervention including discussing their motivation for quitting, offering tobacco cessation medication, and promoting a free telephone quitline. The primary outcome was abstinence at 3 months. Univariate logistic regression identified factors associated with tobacco cessation.

Results: Forty of 60 eligible smokers enrolled in the study. The mean age and standard deviation of participants was 52.1 ± 12.6 years with a 39.9 ± 11.2 pack-year smoking history. The 3-month quit rate was 35% (14 of 40). Fifty percent (20 of 40) of participants used at least one tobacco cessation medication. Only 7.5% (3 of 40) of patients called the quitline, but each of these participants quit smoking. Successful tobacco cessation was associated with a malignant diagnosis and being the only tobacco user in the home (odds ratio, 4.2; 95% confidence interval, 1.0 to 17.2; and odds ratio, 6.1; 95% confidence interval, 1.4 to 26.3, respectively).

Conclusions: Thoracic surgeons can successfully implement a tobacco cessation program with an excellent rate of abstinence compared with reported cessation rates at 3 months from the literature. Further investigation with a larger sample size, longer follow-up, and improved utilization of the quitline is warranted.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 
Tobacco is the single greatest cause of disease and premature death in the United States [1, 2]. It is responsible for more than 5 million deaths each year and a third of all cancer deaths [3]. Smoking accounts for nearly all lung cancer cases (87%), and despite a decline in tobacco use, nearly one quarter of American adults continue to smoke cigarettes [4]. Recent studies from the Society of Thoracic Surgeons General Thoracic Surgery Database continue to demonstrate that smoking is associated with postoperative complications after lobectomy, pneumonectomy, and esophagectomy [5–7].

Thoracic surgeons play an important role in the treatment of tobacco-related diseases such as lung cancer, emphysema, and coronary artery disease. Although tobacco is the single most important correctable risk factor for mortality in the United States, surgeon-directed efforts to promote tobacco cessation are extremely scarce [2]. The purpose of this study was to prospectively evaluate a brief tobacco cessation intervention offered by surgeons in an outpatient thoracic surgery clinic. The primary outcome was 7-day abstinence at 3 months.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Discussion
 Acknowledgments
 References
 
Research Participants
Adult patients were recruited from the general thoracic surgery clinic between January and December 2008. Patients were eligible for the study if they were adults smoking more than 5 cigarettes per week and in the contemplation, preparation, or action (quit less than 1 month) stages of change [8, 9]. Participants needed to be able to consent and not be pregnant. All eligible patients were invited to participate in this research. Consenting subjects completed a tobacco use survey detailing their demographic information, social history, and smoking history. This study was approved by the University of Virginia Institutional Review Board (number 12752).

Brief Office Intervention
All patients enrolled in the trial had a brief office intervention with a thoracic surgeon and a clinical research nurse lasting less than 10 minutes. The intervention included discussion of a participant's smoking history, previous quit attempts, and their current motivation for quitting. During the session patients were offered tobacco-dependence treatment and use of a free telephone quitline, and were provided written materials for their medication and quitline use.

Tobacco Dependence Treatment
Pharmacotherapy for smoking cessation includes seven first-line medications (bupropion SR, varenicline tartrate [Chantix], nicotine gum, nicotine inhaler, nicotine lozenges, nicotine nasal spray, and the nicotine patch. Medications were prescribed for patients following the guidelines from the US Department of Health and Human Services [10].

Quitline
Participants were instructed on how to use quitline, which is a free telephone intervention that has been proven to double the chance of tobacco cessation [11]. It is available, toll free, in both Virginia and West Virginia [12]. Users register during their first call and are paired with a quit coach for tailored counseling. Sessions last from 20 to 40 minutes, and users may call as often as they like. Physicians and patients may learn more about the programs at:

Virginia: 866–784–8454, http://www.freeclear.com/Quit-For-Life/
West Virginia: 877–966–8784, http://www.bebetternetworks.net/wvquitline_home.html

Outcome Measurements
A clinical research coordinator from the Surgical Therapeutic Advancement Center (STAC) was present at thoracic surgery clinics to facilitate ongoing clinical trials. New consenting patients and their tobacco assessment survey were entered into the institutional review board–approved thoracic surgery tobacco cessation database (number 12752). An enrollment log was maintained. The research coordinator documented the tobacco-dependence treatment and scheduled 3-month follow-up visits to administer the follow-up surveys. If patients were not scheduled for thoracic surgery follow-up, the survey was administered over the telephone. Information obtained in the follow-up survey included abstinence at 3 months, medication use, quitline use, and exhaled carbon monoxide analysis.

The primary outcome was 7-day abstinence at 3 months. Factors associated with quitting were evaluated using univariate logistic regression analysis. Variables included in the logistic regression included age, sex, marital status, race, education level, age the participant began smoking, number of cigarettes smoked per day, number of times participant attempted to quit, confidence in quitting (1–10 scale), importance of quitting (1–10 scale), readiness to quit (1–10 scale), type of participant (preoperative, postoperative, or follow-up), presence of a malignant diagnosis, presence of other smokers in the home, use of the quitline, and use of a tobacco-cessation medication.

Outcome Validation
A portable carbon monoxide analyzer (Smokerlyzer, Bedfont Scientific) was used to verify tobacco use during the enrollment session. It was also used to validate self-reported smoking cessation at the 3-month follow-up visit. The cutoff value is 7 ppm in the expired alveolar air from a deep breath.

Data Analysis
Univariate frequency and descriptive analyses were performed on variables of interest. Continuous variables are reported using mean and standard deviation, and categorical variables are reported using frequency (percentiles). All analyses were performed using SAS 9.1.3 software (SAS Institute, Cary, NC).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Discussion
 Acknowledgments
 References
 
Sixty current smokers were invited to participate in the trial. Forty people (66.7%) enrolled in the trial, and 37 participants completed the trial (61.7%). Participant characteristics are shown in Table 1. They were classified as preoperative (enrolled before planned surgery), postoperative (enrolled after surgery), or follow-up (enrolled during follow-up without having surgery). The smoking characteristics of the participants are shown in Table 2.


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  		Table 1 Patient Characteristics
 

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  		Table 2 Smoking Characteristics
 
The primary outcome of 7-day abstinence at 3 months was 35% (14 of 40). Thirty-seven participants completed the trial, and the 3 dropouts were counted as failures (continued smoking). Fifty percent (20 of 40) used a tobacco-cessation medication, and only 7.5% (3 of 40) called the quitline. Interestingly, each of the 3 participants who called the quitline had quit smoking at 3 months. There were 19 participants who returned for an office visit at 3 months to facilitate carbon monoxide measurements. All 19 validated their verbal result (9 of 9 in the quit group and 10 of 10 in the smoking group).

Univariate logistic regression was performed to identify factors associated with success at quitting (Table 3). The diagnosis of malignant disease and being the only smoker in the home were the only two factors associated with quitting (odds ratio, 4.2; 95% confidence interval, 1.0 to 17.2; and odds ratio, 6.1; 95% confidence interval, 1.4 to 26.3, respectively).


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  		Table 3 Factors Associated With Tobacco Cessation
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Discussion
 Acknowledgments
 References
 
Thoracic surgeons receive little training in promoting tobacco cessation despite the impact of tobacco use on their patients. Clear guidelines have been established by the Department of Health and Human Services to help physicians address tobacco use [10]. The US Preventive Services Task Force strongly encourages brief smoking cessation interventions by physicians [13]. These "brief" interventions have been identified as a priority among recommended clinical preventive services owing to their potentially high yield in quality-of-life years saved. Tobacco-cessation counseling is also included as an integral part of the National Comprehensive Cancer Network Guidelines [14]. Surgeons who do not participate and document smoking cessation counseling may be practicing below the standard of care.

Unfortunately, the topic of tobacco cessation is discussed in fewer than 50% of physician office visits. These brief counseling sessions typically last less than 5 minutes, and the majority of brief interventions involve the 5 A's (ask, advise, assess, assist, and arrange) as a unifying construct in providing behavioral counseling interventions [15].

Few trials have specifically targeted tobacco cessation in general thoracic surgery patients. Dresler and colleagues [16, 17] reported their findings on smoking cessation after lung cancer resection from an observational study of 362 patients at Washington University. They demonstrated that smoking cessation occurs in the majority (86%) of patients after lung cancer resection and the longer a patient is nonsmoking preoperatively, the more likely they are to remain nonsmoking. Importantly, half of the patients in their study had quit smoking before surgery. Gritz and colleagues [18] recently reviewed the successes and failures of smoking cessation in cancer patients. Continued smoking after cancer diagnosis has substantial adverse effects on treatment effectiveness, overall survival, risk of second primary malignancies, and quality of life [16, 17]. Schnoll and colleagues evaluated a brief physician-initiated quit-smoking strategy in a cooperative clinical oncology setting [19]. The trial included a total of 432 patients and randomly assigned them to a National Institutes of Health physician-based smoking intervention or standard care. The 6-month quit rates were not statistically different, but patients were more likely to quit if they had lung cancer. Thomsen and colleagues [20] performed a meta-analysis examining the effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation rates. They included 11 randomized controlled trials containing 1,194 patients and found that preoperative smoking interventions significantly reduced the overall complication rate (pooled risk ratio, 0.56; 95% confidence interval, 0.41 to 0.78). The effects on postoperative smoking cessation rates were more variable with higher intensity interventions showing greater success.

This pilot study demonstrates that thoracic surgeons can implement a successful tobacco cessation program. Our 3-month quit rate was 35%. This compares quite favorably with historical spontaneous quit rates of 5% and reported 3-month quit rates from prospective trials between 11% and 18% [11, 21–23]. More than 65% of our patients come from outside our hospital's primary service area with considerable travel times to our clinic. Therefore, the intervention was designed to be feasible during an outpatient thoracic surgery clinic visit and to use tobacco cessation adjuncts that could be performed at a patient's home. Interestingly, only 50% of participants used a medication and very few (7.5%) used the quitline despite receiving the information and demonstrating an understanding for its proven success [11].

This study has several limitations. First, it is a small, single-arm, prospective trial, without comparison with similar patients who did not receive the intervention. Second, longer follow-up would also provide an improved assessment of the intervention. Three-month follow-up is the minimum follow-up suggested by the US Public Health Service for tobacco cessation interventions [10]. Given that only 50% of participants used tobacco cessation medication and only 7.5% called the quitline, it is not clear whether the intervention, rather than the specific participant population, was responsible for the 35% quit rate. In addition, there is an obvious selection bias for participants who chose to participate. However, this is common for most tobacco cessation trials and our 3-month quit rate compares very favorably with other reported rates. Finally, almost half (21 of 45) of the participants responded to the 3-month follow-up by telephone. Therefore, it was not possible to validate their smoking status with the carbon monoxide analyzer. However, 19 patients did undergo 3-month carbon monoxide analysis and all of them validated their responses.

Surgery may provide a golden opportunity for smokers to quit, with great benefit to their health [24]. For example, even in the absence of any specific intervention by medical personnel, the rate of spontaneous quitting is increased in surgical patients compared with the general population of smokers, especially in those undergoing more extensive procedures [25]. Effective tobacco cessation interventions, modeled on those currently available in ambulatory settings, could take advantage of this natural tendency and further increase quit rates. Surgery could thus serve as a "teachable moment" to promote prolonged abstinence, if "only we will take the time to teach" [26, 27].

The telephone quitline is a very useful adjunct to tobacco cessation efforts. In a prospective randomized controlled trial of 3,282 participants embedded in the California Smokers' Helpline, the quitline doubled the chance of quitting [11]. Unfortunately, very few of the participants in our pilot trial actually used the quitline (3 of 37). The dental clinic at the Mayo Clinic in Rochester, Minnesota, recently reported the outcome of a randomized controlled pilot study comparing a brief counseling intervention with a brief counseling intervention and a referral to a tobacco use quitline [28]. Their pilot study evaluated 82 patients and found that referral to a quitline was feasible in the dental clinic with cessation rates of 25% at 6 months. However, similar to our study, compliance with the quitline was relatively limited.

Tobacco cessation is an extremely difficult process. Although surgeons understand its importance, surgeon participation with tobacco cessation trials has been extremely scarce. This pilot trial demonstrates promise for a quick and inexpensive tobacco cessation program directed by thoracic surgeons. The program is feasible for delivery in a thoracic surgery clinic and used a brief discussion with a surgeon, discussion of appropriate tobacco cessation medication, and information to use a free quitline. Further investigation with a larger sample size and longer follow-up is needed to confirm these results and better understand the contribution of the components of the program to its success with thoracic surgery patients.


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
Acknowledgments
 References
 
DR JOHN A. HOWINGTON (Evanston, IL): Doctor Kozower, an outstanding presentation and thank you very much. It was a record, a month before the meeting, getting me the manuscript. So I appreciate that. I also appreciate you tackling an important problem for thoracic surgical patients. I am going to keep it brief to keep us on time. Two questions.

Have you now adopted routine smoking cessation counseling in your clinics now that you have had this success, and have you talked to your cardiac and vascular colleagues about adopting it in their clinics? And you noted that only half the patients took the medication. Was there a higher percentage of patients that quit successfully that took medication than those that didn't? And based on the fact that if they were the only smoker in the house they had a higher success rate, do you now counsel spouses to quit smoking so that if no one in the house is smoking, they are more likely to successfully quit smoking? Again, an outstanding presentation and a great paper.

DR KOZOWER: Thank you very much. To answer your first question, I have made it a point to offer all smokers tobacco cessation counseling. We have added a box on our history and physical forms to more easily identify current smokers. The reality is that only about 20% of our patients are current smokers and brief counseling can be done in about 5 minutes.

To answer your next question, we have talked to our colleagues in cardiac surgery and are initiating a larger trial with cardiothoracic surgery patients. The populations are a little different but both are potential "teachable moments."

Your final question referred to factors associated with tobacco cessation. We did a univariate analysis of factors associated with cessation success, and in this small study, medication use was not significant. Being the only smoker in a household was significant, and I do include family members living in the same home in cessation counseling. The reality is that if the family members accompany a patient to their outpatient consultation, it only makes sense to include them in the cessation counseling.

DR MARK J. KRASNA (Towson, MD): Two quick comments—a great paper. At St. Joseph Cancer Institute we instituted a policy where all the health care providers, not only physicians but all the nurses, have actually taken the test and they are all now official smoking cessation counselors. As you said, it is very easy, very straightforward, and what is nice is that there then is consistency across all disciplines. It is almost like your sixth vital sign. After you find out if the patient is in pain or not, the next thing you ask them is, are you smoking or not, and if they are, they have to go back to the quitline or we have a smoking cessation counselor. I would just congratulate you but tell you that definitely get the other health care workers involved.

Lastly, to remind the group that the joint task force of the STS and AATS have recently come out with a publication from the Workforce on Thoracic Surgery on smoking cessation and the importance of quitting, including the quitline. So good work, Ben. Thank you.

DR KOZOWER: Thank you.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 Acknowledgments
References
 
This study was funded by a grant from the American Cancer Society (IRG 81-001-17). Doctor Kozower is also supported by the Agency for Healthcare Research and Quality (K08-HS18049).


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 

  1. Ezzati M, Lopez AD. Estimates of global mortality attributable to smoking in 2000 Lancet 2003;362:847-852.[Medline]
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  6. Wright CD, Kucharczuk JC, O'Brien SM, Grab JD, Allen MS, Society of Thoracic Surgeons General Thoracic Surgery Database Predictors of major morbidity and mortality after esophagectomy for esophageal cancer: a Society of Thoracic Surgeons general thoracic surgery database risk adjustment model J Thorac Cardiovasc Surg 2009;137:587-595.[Abstract/Free Full Text]
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  14. National Comprehensive Cancer Network NCCN Clinical Practice Guidelines in Oncologyhttp://www.nccn.org/professionals/physician_gls/f_guidelines.asp 2001Accessed December 2009.
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