Have You Been Thinking About Quitting Smoking? March 25, 2009 Abigail Halperin, M.D., M.P.H Donna Manders, M.P.H. David Eaden.

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1 Have You Been Thinking About Quitting Smoking? March 25, 2009 Abigail Halperin, M.D., M.P.H Donna Manders, M.P.H. David Eaden Please remember the opinions expressed on Patient Power are not necessarily the views of Seattle Cancer Care Alliance, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. Introduction Quitting smoking is one of the hardest things to do. If you're a cancer patient it is something very important to do to help your cancer therapy go better and have the chance for a longer, healthier life. The Seattle Cancer Care Alliance has a special program to help you and even a spouse who may smoke too. All that coming up next on Patient Power. Hello and welcome once again to Patient Power, sponsored by the Seattle Cancer Care Alliance. I'm Andrew Schorr. One of the toughest things to do when you're trying to have the best possible health is if you've been a smoker is to quit smoking. And tobacco, and we'll hear more about it, I'm told, is one of the most addictive substances. And we know it's got to be tough. Imagine our president, President Obama, still smoking I believe and how difficult it is to stop. Well, it is also something to think about when you have cancer, and did you know that if you're being treated for cancer that therapy can go better, your life expectancy can be better, your recovery can be better if you are not or no longer a smoker. So not surprisingly one of our leading cancer organizations, the Seattle Cancer Care Alliance, in 2007 established a smoke-free life program. And they've been helping cancer patients who were referred by their doctor to the program. And also they've been helping other family members who are also smokers, and then they can do it together. So I want you to meet someone who has gone through the program and has been smoking, started at age 13, now he's 78 years old. Dave Eaden joins us from Everett, Washington, but it was his wife, Lois, they've been married 35 years, who was treated for the same leukemia that I was treated for, chronic lymphocytic leukemia, and it was out of that that came the recommendation, hey, Lois and David, it would help you if you join this smoke-free life program. So you are a retired mechanical engineer, married 35 years to Lois. She goes through cancer treatment, and you're told, hey, let's see if we can help you quit smoking now. You have for almost a year supporting one another, but this program I know made a lot of difference because you tried before, right? 1

2 Oh, yes. I'm sure most people have. I've tried several times with different professional programs from other healthcare givers but never was able to make it stick. What made the difference? Challenges of Quitting Smoking I think the difference in this program, to me it was the personal responsibility. Other programs, they just kind of ran things in a group, and the whole group was expected to quit on the same day, and it was programmed, and it was well done, and in some ways maybe more technical and documented than this program, but this program put you in charge, and that to me was the scary part. I think the magic of their program is you pick a date and then you live with it. And they're there to support you in making it happen. Very, very, very professionally, yes. Now, Lois was your partner in this. Was it difficult for her? And with you being there and doing this together did that make it easier? Yes. For the two of us, I think I was more programmed to want to succeed and had tried before, and Lois never really had, and every time the subject came up, nothing ever happened. And with the obvious setback and knowledge of her health when the cancer was discovered and the work with Dr. Gernsheimer there at Cancer Care, when she brought this all together it was pretty hard for Lois to say no or to say I'll think about it or something. So she was extremely insistent, very persistent as a matter of fact, and she needed to be to get Lois across that first bar. So it was a good program in the way it's, I'm not sure we would have gone there or been as successful if there hadn't been this deeper demand from her primary caregiver. Right, and the cancer doctor saying we're treating you for the cancer but to really make everything work you and ideally you and your husband together if you can quit smoking that will make a big difference for the cancer care as well as your overall health. Well, let's learn more about that. 2

3 I want to introduce first the director of the Seattle Cancer Care Alliance Smoke-Free Life Program. That's Dr. Abigail Halperin, and she's been involved in smoking cessation for a long time, and now she'd dedicated to it for the last couple years now in working with cancer patients and their families. Dr. Halperin, so what's the connection with, why do it at the cancer center? What's unique about that? There are a lot of smoking cessation programs out there, and we heard David say he's been in some. What's the connection with actual cancer patients and their families? Part of the difficulty for cancer patients in terms of smoking, of course about 30 percent of all cancers are caused by smoking, and so a lot of the patients who come in are smokers, either past smokers or current smokers. And when they start cancer treatments their lives are just really just thrown off and they're in an incredible stressful situation, and a lot of them think oh, how can I quit smoking now because I'm so stressed out and this is how I've learned to deal with my stress. But in fact if they do quit smoking their chances of surviving and of responding positively to their treatment and getting through their treatment with minimum complications is greater if they quit smoking, even at the time of their diagnosis. And a lot of cancers that people get are not fatal but would be more likely to be fatal if they're smoking. So both length and quality of life are markedly improved if they can quit smoking, even in the face of a cancer diagnosis. But somebody who has smoked for years and years and years, many people, not all, but many people develop cancer in their senior years and they say, you know what, not only do I need it as a crutch and a support but it's been a part of my life so long why is it so important to quit now? Yet in so much of what I read it says, well, any time is a good time to quit. Maybe you could help us understand that. Well, the sooner somebody quits the better off they are. And in fact in terms of prevention when people are smoking and, the longer they smoke, the more they smoke, the more number of cigarettes per day and the more years that they smoke, the greater their chance of developing a tobacco-related cancer, so the sooner they quit the letter. In terms of facing cancer treatment, chemotherapy works better if you're not smoking. It's more effective. If you're having surgery your risks from that surgery in terms of both healing, mortality, getting pneumonias and other diseases that can complicate your recovery are much higher if you're smoking before that surgery. In fact the longer you quit before that surgery the better chance you have of coming through that surgery successfully and having it do its job. We're going to meet your partner with the program in just a minute, Donna Manders, but I wanted to pose this question we received to you because it relates to what you just talked about. This came from Oscar who wrote in, "Dr. 3

4 Halperin, I'm a long-term smoker of over 50 years. I'm having inguinal hernia repair in about two weeks. I have been told that my lungs may get worse before they get better. If I quit smoking now it may interfere with my breathing during my anesthetic and after surgery. Is this true?" How the Body Recovers After Smoking I think there may be a slight misunderstanding there in the sense that as soon as you quit smoking the damage to your lungs from the direct injury to the lungs caused by smoking, which is called emphysema, anyone who has been smoking that long will have some degree of destruction from their smoking. And having emphysema when you go into surgery does cause complications, makes it harder for the anesthesia when you're on a respirator. You can develop pneumonias more easily. You can develop lack of oxygen more easily. You have to use higher levels of oxygen to keep a person well oxygenated. But what I think they may be misunderstanding is when you first quit smoking what happens is the cilia in your lungs that have been paralyzed by the smoking, that's one of the damages caused by smoking, will start to recover pretty quickly. And what happens is they start doing their job which is to help clean out the lungs. So the lungs will start producing a little bit more phlegm, and people will be coughing up more phlegm for a while for the first weeks, two or three weeks after they quit sometimes. But that doesn't mean they're more damaged. It actually, it's an apparent symptom that makes people think, oh, my lungs are getting worse, but they're not. They're just cleaning out some of that tar and some of the inflammatory cells and debris that have been caused by their years and years of smoking. But that would not be a problem with in terms of the anesthesia. What's a problem is the underlying emphysema that's been caused by those years of smoking. Any time is a good time to quit smoking. Yes. The sooner the better, but it's never too late. All right. Well, someone who works very closely with you is Donna Manders, and Donna is the clinic coordinator of the Seattle Cancer Care Alliance Smoke-Free Life Program, and she is a smoking cessation specialist. So Donna, people are referred typically by their cancer doctor to your program, which is tied in with the lung cancer early detection and prevention program, and tell us what you do. And tell us how your program is individualized to them, or in the case of like with David and Lois to a family where more than one person is trying to quit. 4

5 Ms. Manders: Okay. Well, thank you for such a great question. People are referred to us by their physicians, and what I typically do is call the person is ask them if they're interested in quitting and let them know that I understand that from their healthcare provider that they may very well be interested in quitting, and what I then do is ask the person if they say, yes, I'm interested in quitting, I ask them what's motivating them personally, what is it that matters to them, and why do they want to quit. Because people's personal reasons for quitting are the most important reasons. And once I understand what it is that's motivating them, and it may be many different things. It could be the recent diagnosis of cancer. It may be concern about the expense of smoking. It may be concern about secondhand smoke around the grandkids. There's many, many, many different reasons that people give me to wanting to quit, and I can't stress enough that people's personal reasons for quitting are the most important ones. And then I also find out from them, if they're thinking about quitting what kind of time frame are they interested in. Is there a special day coming up soon that would be a good day for them to quit. Is there a reason that they might want to quit immediately, or would they rather wait for a little bit? And what we do is we come up together with a date that would work well for them to actually put down the cigarettes. And then when we're on the phone I ask them a little bit more about what would stop them from succeeding. Can they identify the impediments that could actually get in their way. And sometimes they will actually say things like my husband smokes, or my caregiver who is taking care of me right now when I'm dealing with my cancer, they smoke. And sometimes when I talk with a person about their source of support the person will say, well, you know, actually my husband or my caregiver does want to quit as well and they will support me when I quit and they want to quit too. And that is just music to my ears because I do know from working with literally thousands of people who were quitting over the past decade really, I really learn that when people who are supporting the person quitting also quit they're going to increase the likelihood that the person trying to quit is going to succeed. So oftentimes I will actually end up talking on the speaker phone with people who are interested in quitting and the patient, and we all talk about steps they can literally start today to get ready for the quit. And then we invite the people if it's possible, sometimes people live far away or sometimes unfortunately they're too ill to make an extra trip in, but oftentimes they'll come into the clinic. We'll meet with them both personally, the spouse or the caregiver, and we continue to talk about the plan and what their next steps are to get ready for the quit date. And then Dr. Halperin will also talk with them about quit-smoking medications available and how those quit-smoking medications will increase the likelihood that they're going to succeed in not only quitting but staying quit. That's pretty much what we do. 5

6 Let me hear a little bit from David's point of view. So David, you and Lois went through this. You're coming up on a year of having quit. What were the challenges? I think the challenges were very early on when the encouragement from Dr. Gernsheimer, caregiver for Lois, she was after us for almost a year to start doing something, I believe even before this program was an option. And then when that was an option and Lois's procedures were showing good signs, why, of course we had the opportunity, because it was offered jointly with her care it was almost very difficult to say no, we're not going to bother talking to these people. So it was the combination of the actual surgeon that you're working with, their assistance, and then the great support that the others have and their knowledge. So it was very difficult to avoid them. Keys to Successfully Quitting Right. Well, it sounds like it's very one-to-one. So, Dr. Halperin, help us understand. This is such a tough addiction. Everybody, you know, I've ever talked to who is smoking has tried to quit. What are the keys to success from your point of view? And what are some of the medical tools that can help now? You know, it's interesting because most people who decide to quit smoking will just sort of decide on the spur of the moment and just try to quit on their own. The vast majority of people don't really understand that there are tools to help them quit. They think that it's just a matter of willpower, and they don't acknowledge that this is a very deeply imbedded addiction. And they judge themselves. They feel guilty, particularly if there's somebody who has gotten a cancer diagnosis. They feel like it's their fault. But it's not their fault, because nobody intended to get addicted to tobacco. People hear that it's not healthy, but it's hard to believe that when you're a teenager and you start smoking and it's cool and you don't feel any ill effects of it until many, many years later. So it's a very deeply ingrained addiction, and people feel like they have chosen it. They've been kind of brainwashed, partly by the tobacco industry and all the advertising that this is their choice, and it's not their choice to be addicted. And when they first try to give up they don't realize how hard it's going to be. And as I said they think it's just a matter of willpower. Oh, I decided to smoke, I can decide to quit. And that's a part of it, but there are many tools that can help people overcome the addiction, the immediate withdrawal, because there's severe withdrawal for several weeks after people stop smoking. 6

7 And there are several medications that are extremely effective in reducing those withdrawal symptoms while the person is going through the steps of the quit plan that Donna discussed of sort of reordering their lives and changing their lives to become nonsmokers. It's not just a matter of quitting smoking. You actually have to become a nonsmoker. So we've got some really helpful medications. The oldest and sort of tried and true medications are just nicotine replacement therapy. A lot of people think that these are dangerous, that the nicotine is one of the harmful ingredients in tobacco, but it's not. It's the addictive part of it, but it's not harmful in and of itself. It's very similar to caffeine in terms of the fact that it's a stimulant, but it's the drug that in your brain stimulates the rewards, the reward system in your brain for the smoking and what reinforces it and makes it associated with everything you've done in your life that's either pleasant or fun or when you're dealing with stress. So that's why it's so hard to give it up because it becomes so hard wired into your brain, the smoking. But the medications, the nicotine replacement therapy at first which is patch, gum or lozenge and sprays too. But now there's two other medications that have been approved that work on the level of the brain. One works at the receptor level, which is the new medication called Chantix or varenicline. Then there's an older one that's an antidepressant called Wellbutrin. The generic term is bupropion or Zyban for smoking cessation, but that also works on that same reward system. But what all three medications do is over the course of two to three months they provide you with relief from the craving. Not a hundred percent relief but enough relief that you can start reforming your life and your patterns to be rid of that tobacco, that nicotine addiction. So I want to go back to Donna to just understand a little more logistics. So your doctor, in this case probably your cancer doctor or another physician associated with the SCCA, makes a referral to you, and it can include a family member, to the program. And then you're right on there with them to help personalize the program. Dr. Halperin plays a role with these tools and assessment, and then you're there for them on the phone and every step of the way as you establish a date to help get them towards the goal that they've established. Did I say it right? Ms. Manders: Exactly. Success Rates Okay. Now, tell us about success rates. We're talking about maybe one, if not the toughest addiction one of the toughest addictions and a habit that's gone on for decades for so many of the people. What can they hope for? I know it requires a lot of work, and David was telling me before the call it was one of the toughest 7

8 things he's ever done. But what hope can you give them that they can actually get to the point where David and Lois are, almost a year having been quitters? Ms. Manders: Well, what I always say to people first is it's very common to try several times before you succeed, and I remind people that every time they've tried to quit they're closer to succeeding than they were before. This is a lot like learning how to ride a bike. You get on the bike. You fall off a few times, maybe even fall into a ditch or hit a pole, but if you keep on getting up on that bike you will make it. You will ride around the block. So I encourage people to realize it's going to take seven to ten times on average for them to succeed. The population statistics, of the people, so about 70 percent of all smokers, and there are 45 million smokers in the United States. About 20 percent of the population is still currently smoking, about 70 percent of them will say that they really want to quit, and about 50 percent of them will try to quit every year. But only about five percent of those who try on their own are successful. Whereas those who go into a program like the Tobacco Quit Line, like our program, their percentages, their success rates are somewhere between 35 and 50 percent success. So you really see about a seven- to tenfold increase when people combine counseling, developing a quit plan, getting support and medication. All right. Now, here's an we got from Karen who wrote in. "How long does it generally take to quit smoking, and is it harder the longer you have been a smoker?" Dr. Halperin? I think there are many factors that contribute to the quitting, or to the probability of success if we want to frame it more positively. The longer you've smoked, it is true for most people the more you smoked and the longer you smoked the harder it is to quit because you're creating more receptors in your brain that need to be satisfied, and so there's sort of a physiologic limitation in that. So the younger you are when you start the more receptors you're going to form. Very few people start smoking after the age of 18 and almost none after the age of 21 because people, you have to form those receptors when your brain is still developing in order to become highly addicted. And there are also people whose personality types are more addictive than others. So maybe five to ten percent of smokers are able to stay occasional smokers, and we've had some of those people. But it's still really hard for them to quit, but it's probably easier in certain ways because they're not as strongly physiologically addicted, but psychologically they may have the same amount of attachment to their habit. So it's not strictly measurable by quantity. 8

9 This comes in from so many people. So we know that there are many, many health benefits to stopping smoking at any age. However, we're talking about you all at the Seattle Cancer Care Alliance, and you're tied in with the lung cancer early detection and prevention program, and so we get questions like this. And I'd love to know how you answer it. This one is from Sam: "How long has the average lung cancer patient smoked at the time of diagnosis?" Because he said, "My mother quit smoking just over ten years ago, but for the 40 preceding careers she was a heavy chain smoker, consuming more than three packs a day. Last week at age 75 she was diagnosed with lung cancer, and she did not have cancer at the time she quit smoking. She thought she'd escaped the risk of developing lung cancer." So help us understand. We know about the heart benefits and so many other benefits, but people who smoked and then quit years ago they actually still have this worry about lung cancer or should be aware of it. What's going on there? Dangers of Lung Cancer for Smokers Well, the risk of lung cancer is entirely dependent on how much you have smoked in your life. And the latency period for lung cancer, the amount of time it takes from the time it develops and you can't find it, it's undetectable, until it's detectable is somewhere between 10 and 20 years. So your risk for lung cancer is basically set at the time you quit but will increase if you don't quit. So it increases over time. As soon as you quit the risk stops increasing. But you will still have whatever risk you have up until that point. So the risk doesn't go away, but if you have survived ten years without your lung cancer showing up that means your chance, they say, okay, so now you're sort of 50 percent there. Your lung cancer risk has gone down 50 percent. But in 20 years you're getting much closer to the fact that if it hasn't shown up by now you probably didn't have it. But you have that 10- to 20-year latency period, so a lot of people who are long-time smokers if they haven't already started their cancer and they stop then they're not going to get a cancer. But you don't know. There's no way of telling at the time that they quit whether they have it or not. Now, the lung cancer early detection program tries to find it as early as possible, so it will screen people in the sense of using a high resolution spiral CT scan and try to detect those cancers when they're very early. Now, like breast cancer or prostate cancer, some lung cancers are what we call indolent. They're very small and they're very slow growing and they'll never be a problem. They aren't the kind that will eventually cause fatal lung cancer. But you can't really tell the difference between them until they've grown and become aggressive or metastasized, so it's very, very hard to catch them early. 9

10 But we see this a lot with older people who quit. If they've already got that risk, if they've already started that lung cancer process which is undetectable, then stopping isn't going to prevent the lung cancer. However, if it's detected early and they're no longer smoking their chances of actually surviving that lung cancer and getting it, if it's small enough they excise it, they have their chemo, they're much more likely to respond to that treatment if they're no longer smoking. I want to go back to Dave. So, Dave, you've lived through all this with your wife with cancer and both of you quitting smoking. We have listeners who are people like you were, and that is they are, have tried to quit probably many times. It's certainly been recommended by their doctor. Maybe someone has been diagnosed in the family with cancer, and they've been told you will do better if you can quit. What would you say to them to give them some encouragement and check out this program? I think all smokers through education in the last 30 years, the danger of smoking. Years ago which I started there was no knowledge that it was, and so then it just becomes a matter of time and when you're finally going to take it seriously. And Donna is actually right in the fact that you do quit and fail, and you do try to quit on your own, and you try different things, but you have to really be prepared for it. And you are just unconsciously because of all of your thoughts and concerns and the worries in the middle of the night and your other failures that it finally becomes the right time. And with this program, with the support of Dr. Halperin and the different medicines or cocktails that could be put together to get over some of that, just the raw physical problem, the addiction part of it rather than the psychological part. So that all helps. And then their approach of the time certain as your responsibility. And it works good. It's different for everybody, and it has been for me. I once quit for seven and a half years and started again, so it never lets go of you. Well, I just want to congratulate you and Lois for making it happen. I want to wish you many years of happy, healthy marriage. I'm so delighted she's in remission, as I am, deep remission with her CLL. And just celebrate life. Enjoy it, and feel good, and I know you'll always be reminding yourselves, as my mother did when she quit smoking is she just was so proud of herself and she just kept that pride going. So all the best to you. The biggest whip was when you finally get 13 teenage grandchildren, a lot of them girls who get after you. Right. 10

11 They can be quite vicious themselves. Right. Right. Right. Well, that's good in that they don't smoke. Well, that is so good. David Eaden, thank you so much for joining us. Yes. I just want to get some final comments from the ladies who really make this program happen. And I want to make sure I give the numbers right. So if someone listening wants to get in touch with either Dr. Halperin, the director of the program, Donna Manders, the smoking cessation specialist and clinic coordinator for the SCCA Smoke-Free Life Program, let's see if I got this right. So first of all they can go on the website and they can look under Prevention Clinics and there's the lung cancer early detection and prevention clinic, right? And website of course is seattlecca.org. And then you've got some phone numbers they can call as well, Donna. What numbers would you recommend they call? Ms. Manders: Well, in terms of getting immediate help in terms of quitting wherever you are in the country there's a number called QUIT-NOW that anybody can call and get immediate support from a smoking cessation specialist. And that number also is They can go to the web at And finally if your interested in being a patient here at the Smoke-Free Life Program have your doctor refer you to the lung cancer early detection or prevention clinic. Or the Smoke-Free Life Program. And there you go. And seattlecca.org/smoke-free-life.cfm is actually the website. But it's easy. Your doctor if they're associated with the Seattle Cancer Care Alliance will want to help you quit smoking and know about this wonderful program. Dr. Halperin, I'm going to give the last word to you. I have a couple of things I want to clarify too. So the lung cancer early detection prevention program is really more for people who have risk for lung cancer or already have nodules that their doctors refer them to that program to get evaluation to see if they are lung cancer or not. And if they are current smokers they will automatically be referred from that program to ours. But we also, about half of our patients come from the rest of the Seattle Cancer Care Alliance. 11

12 Like Lois, with leukemia. Exactly. Or a lot of breast cancer patients, ovarian cancer patients, leukemia, lymphoma, we get them all. Any patient with cancer who is a smoker is going to do better if they quit smoking. So our referrals come from any oncologist in the Seattle Cancer Care Alliance, or any doctor, any surgeon can refer to us. And this program you said is about two years old now as we do this in About a year and a half. We started about a year and a half ago. It sounds so special, I guess, and I mean that in all the best ways is that as we age there's more risk of cancer, lot of cancer survivors and better treatments. We want to do well. We want to have a good life after beating or beating back the cancer and stopping smoking seems to be a great place to start. Yes. And the other thing about quitting smoking that I have to mention, I know some of the oncologists even are worried about asking their patients to quit smoking because they're afraid that they are already under so much stress from their cancer that trying to quit might make things more stressful. But in fact people are so much less stressed once they succeed in quitting. They feel so much better, as Mr. Eaden said, about how proud people feel of themselves when they're able to quit, and they just feel so much healthier anyway. People are so happy to have quit. Even, they'll probably survive longer. We know they survive longer and that they feel better. It's a win, though. It's a victory. Yeah, even if the cancer is ultimately fatal they will be so much happier and healthier up until that time. They'll live, the quality of their life will be so much better than it would have been had they continued to smoke. And people are very, very happy, very appreciative of the help. And it's kind of crazy that not all cancer centers have this kind of a program. But you do. 12

13 We do, and we were inspired by M. D. Anderson Cancer Center. They had their program in place a little before we did, and we thought that was such a good idea that we modeled our program partly after theirs. And I think more and more cancer centers really do need to have this service because it's so important. Patients who are getting cancer treatment are often there every single day during their treatments or in and out, and they don't have the ability, it's too hard for them to have to go somewhere else to get a smoking cessation program. So having it onsite is just essential for the success of the people who are trying to quit. Well, I want to congratulate you, and Donna, I want to congratulate you too for the work you do. And as a cancer survivor, I haven't been a smoker but my mother-in-law was, and I just remember, when we got married that was her date. At our wedding date she was no longer going to be a smoker, and I remember her jaw almost falling off, you know, chewing the nicotine replacement gum. And I remember my mother quitting smoking after she was hauled away in an ambulance with pneumonia, and she said, no more of this, I'm quitting. So whatever it is, they did it, and it's just wonderful that you have your program in supporting people who they personally or their family was touched by cancer. Thank you for all you do and for being with us today. I really appreciate it. This is what we do on Seattle Cancer Care Alliance-sponsored programs with Patient Power, and I urge people if you are an SCCA patient or want to find out more information to check out the Seattle Cancer Care Alliance Smoke-Free Life Program. It can make a huge difference for you. I'm Andrew Schorr. Thank you for joining us today. Remember, knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of Seattle Cancer Care Alliance, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. 13