To Quit or Not to Quit {#s3} ====================== As previously described, most individuals who quit smoking completely will do so in response to negative health events. Such events are especially likely after a diagnosis of cancer. Because most individuals who quit smoking after a cancer diagnosis intend to quit for life, the decision to quit should be carefully evaluated. It is often difficult to assess whether a quit attempt will be successful. Among smokers with cancer who tried to quit smoking without pharmacotherapy, the median length of time between cessation attempts was 6.5 months ([@A3]). These findings suggest that the success of a quit attempt is likely to be closely related to smoking history, motivation, and nicotine addiction. A strong motivation to quit should be a critical factor when considering whether or not to quit after a cancer diagnosis. Cancer survivors who are motivated to quit have been found to experience more quit attempts and use more evidence-based cessation aids, such as nicotine replacement therapy, than nonmotivated smokers ([@A3]; [@A6]). Among smokers who are attempting to quit with or without assistance, using evidence-based strategies can double the odds of success ([@A9]). The extent to which a cancer survivor uses evidence-based approaches should be evaluated. It is not sufficient to simply advise cancer survivors that they need to be informed of the benefits of quitting smoking. However, there are some promising smoking cessation interventions that may be applicable for this population. These include brief interventions and the use of tailored health messages for cancer survivors. Brief Interventions ------------------- Brief interventions are used to help patients set realistic goals, such as smoking cessation, within a specified time frame ([@A8]). In addition to improving motivation, this may have long-term effects on the cessation outcome. Brief interventions have been demonstrated to help smokers quit and continue to abstain from smoking for up to 1 year ([@A8]). In addition, it is important to evaluate the effectiveness of the different cancer treatment therapies on a patient's smoking behavior. The ability of smokers to quit smoking after receiving radiation or chemotherapy is not well studied ([@A2]). Additionally, there is limited information on the effectiveness of certain cancer treatment modalities, including surgery, chemotherapy, and endocrine therapy. However, cancer patients who smoke and receive chemotherapy are likely to be at a high risk of relapse ([@A2]). As such, they may be candidates for special cessation programs that involve a combination of pharmacotherapy and behavioral approaches. Evidence-Based Educational Resources ------------------------------------ There is now a wealth of evidence on the benefits of smoking cessation. The tobacco industry does not spend millions of dollars on educational campaigns without a reason. Patients need to be educated on the benefits of quitting and be empowered with the appropriate evidence-based methods for quitting. Smoking cessation aids such as nicotine replacement therapy should be considered first ([@A9]). These brief interventions and smoking cessation aids, when used in combination, may lead to significant improvement in smoking cessation for smokers with a cancer diagnosis ([@A8]). Nicotine replacement therapy is a safe, effective, and available treatment for smokers of all ages. In addition, it may improve a cancer survivor's posttreatment quality of life by easing side effects of treatment. Nicotine replacement therapy may be especially useful for tobacco-dependent survivors of lung cancer ([@A6]). It is recommended that smokers be encouraged to use nicotine replacement therapy or an equivalent therapy, such as an inhaler, if smoking cessation is the goal. For patients using one of these products, clinicians should be aware of the potential benefits of using nicotine gum for smoking cessation ([@A6]). Nicotine gum can be used either on its own or in combination with other products to help smokers quit. Nicotine gum is effective in smokers who are interested in quitting and who have no contraindications to nicotine replacement therapy. Although most smokers with cancer are not able to use nicotine replacement therapy to help quit, additional strategies may be appropriate. Using counseling and other evidence-based methods in combination with nicotine replacement therapy may improve a cancer survivor's chances of successfully quitting. In addition, smokers may benefit from a combination of nicotine replacement therapy with non-nicotine medication. Zyban, a non-nicotine medication, has also been shown to increase the rate of smoking abstinence for smokers with a cancer diagnosis ([@A11]). There are also several nonpharmacologic approaches to tobacco dependence that can be used with patients who are not interested in using nicotine replacement therapy or have contraindications to it ([@A6]). Nicotine chewing gum, lozenges, inhalers, nasal sprays, and skin patches are all forms of nicotine replacement that are available as treatments for nicotine dependence. Nicotine chewing gum can be used without a prescription for tobacco cessation and is available over the counter. Nicotine chewing gum does not treat other symptoms of tobacco dependence and should not be used in isolation. Nicotine replacement products should be considered in combination to help smokers quit ([@A9]). Nicotine chewing gum, lozenges, and inhalers are also effective for smokers who have tried using nicotine replacement therapy, but are not able to use it. A recent study showed that nicotine gum, lozenges, and inhalers have similar efficacy and may all be used for smoking cessation ([@A10]). Nicotine inhalers are available over the counter in various forms, such as patches and sprays. However, a prescription is needed for prescriptions for nicotine inhalers ([@A9]). Nicotine spray should be used in a similar fashion as nicotine gum, not alone. The nicotine lozenge should not be used in isolation but is an excellent adjunct to nicotine replacement therapy. Most smokers need to use more than one form of treatment and clinicians should discuss the effectiveness of using each strategy as it relates to the patient. In addition to using nicotine gum, lozenges, or inhalers, smoking cessation aids such as nicotine replacement therapy should be used in conjunction with each of the smoking cessation strategies discussed. Cognitive behavioral therapy may also be helpful for patients looking to quit smoking. Such therapies may be especially important for smokers with a cancer diagnosis who want to quit because they may provide the coping skills and confidence needed to succeed. A study of smokers with a lung or head and neck cancer found that cognitive behavioral therapy helped most of these individuals abstain from smoking ([@A7]). Quit smoking programs have also been implemented by some cancer centers and clinics to target cancer survivors with smoking behaviors. They may also be helpful for smokers who have tried quitting. Smoking cessation programs should be used in a supportive setting, such as smoking cessation programs associated with hospitals or cancer centers, rather than in a nonprofessional environment ([@A2]). Smoking-cessation programs can help reduce a patient's anxiety about quitting, which can lead to increased success. Nicotine-replacement therapies can also help alleviate the anxiety associated with a cancer diagnosis ([@A9]). It has been shown that many of the fears and anxieties associated with cancer, smoking cessation, and the possibility of relapse can be associated with symptoms of depression and anxiety ([@A2]). Depression and anxiety levels have been found to be negatively correlated with smoking behavior, with cigarette consumption positively correlated with the intensity of depression and anxiety levels ([@A4]). These findings suggest that treating nicotine dependence could be a useful component in the treatment of depression and anxiety. Many cancer survivors are using tobacco as an aid in dealing with certain side effects of cancer and its treatment. Nicotine replacement therapy may be especially important in smokers who need to quit because of side effects of cancer treatment. Smokers who are being treated for a head or neck cancer, in particular, may benefit from nicotine replacement. In these patients, nicotine replacement therapy may decrease the side effects of chemotherapy and increase the likelihood of tolerating the treatment and undergoing it. It is also helpful for cancer patients with lung cancer who are experiencing difficulty tolerating their prescribed radiation ([@A6]). Patients who have undergone surgery for certain types of cancers may have temporary changes in their immune system, which may be more apparent in smokers. Smokers who are being treated for head or neck cancer and are showing signs of a relapse may benefit from nicotine replacement therapy. If smoking is the only means of improving a patient's physical or psychological condition, it may be preferable for the patient to quit smoking ([@A2]). Discussing the benefits of quitting smoking with patients may not be easy, but most physicians feel that this is part of their responsibility to patients. Although physicians are usually taught to avoid discussing smoking cessation because of the legal implications, patients are interested in quitting, which should be encouraged by the physician. Patients may prefer that physicians ask directly about the patient's smoking status. Additionally, because smoking cessation methods have been shown to be effective, it is important for physicians to educate patients about these options ([@A9]). Brief interventions may be the best way to start. Patients who have been diagnosed with cancer are often interested in quitting. Patients who have had a cancer diagnosis will need to be evaluated for their risk of a relapse. However, they also have many reasons to quit smoking, including general health reasons and to improve their chances of being cured of cancer. Smoking cessation is often not a priority for many patients who have been diagnosed with cancer. It is, however, critical to have this discussion to discuss the health benefits of smoking cessation. Although physicians may feel uncomfortable discussing smoking cessation because of the legal implications, the use of evidence-based interventions is necessary to ensure patients are motivated to quit and able to tolerate or tolerate their treatments for cancer. {#T1} **Founded in 1981.** AAFP: American Academy of Family