Tobacco Cessation Medications Research Articles

Disparities in tobacco cessation medication orders and fills among special populations

There is considerable interest in measuring and eliminating health care disparities among various special populations, but there is limited understanding of their extent, causes, or potential remedies. To improve this for tobacco cessation, we measured differences in the frequency of receiving and filling cessation medication prescriptions by race, ethnicity, age, language preference, health insurance, and pregnancy. The relevant variables for all patients of a Minnesota medical group aged 18 years and older with clinician visits were extracted from the electronic medical records of 1 large medical group from March 2006 to February 2007. This was combined with claims data from 1 insurance plan that covered most of these individuals. Order and fill rates for cessation medications were then adjusted for each of the other variables. There were 32,733 current users of tobacco, 18,047 of whom had both health insurance and pharmacy claims data available. After adjustment, 15.4% overall had received an order for cessation medications during this year, but only 78% had filled it. Groups receiving fewer orders than their comparison groups were aged 18-34 years or older than 65 years, men, pregnant women, Asians and Hispanics, and those with non-English-language preference, on Medicaid, or with fewer visits. The same groups were less likely to fill that prescription, except patients with non-English preference or Medicaid. There are disparities in both the receipt of cessation medication orders and the likelihood of filling them for some special populations. The causes are likely to be complex, but this information provides a starting point for learning to improve this problem.

Tobacco Use and Dependence Treatment: A Critical Component of Cancer Care

Failure to address tobacco addiction in patients with cancer is unjustified at best and negligent at worst. Recently, a patient nearing completion of her breast cancer treatment came to our Nicotine Dependence Program. When asked why she wanted to quit, she said that she did not want to go through breast cancer again. She had wanted to quit before beginning chemotherapy, but her physician advised against it, thinking that quitting during treatment would be too stressful. Several concerns help to explain why oncology providers sometimes hesitate to address tobacco use with their patients. Some question the wisdom of engaging in smoking cessation during active cancer treatment. Patients are already overwhelmed and the prospect of coping with withdrawal symptoms and attending additional appointments feels like too much. Some providers are unfamiliar with tobacco cessation medications; others fear that these medications may cause side effects, potentially interfering with cancer treatment. Some question the utility of intervention; if cancer diagnosis did not make the patient quit, then nothing will. Oncology providers who do want to incorporate smoking cessation into cancer care may initially find little institutional support. A comprehensive system may not exist to identify tobacco users and educate providers and patients about effective interventions. Clinicians who do advise patients to quit may not know where to refer them for additional resources and ongoing support. The function of a cancer center is to screen patients, diagnose cancer, and provide comprehensive treatment. Smoking cessation, if provided at all, is often viewed as an ancillary service, outranked in terms of prominence and resources by nutrition, mental health, education, acupuncture, and massage. This is surprising given that quitting smoking is proven to reduce a patient’s chance of a future cancer diagnosis. Research demonstrates that failure to address tobacco addiction in patients with cancer is unjustified at best and negligent at worst. Smoking causes cancer (Kuper, Boffetta, & Adami, 2002). Continued smoking among individuals who have cancer causes more cancer. Patients who continue to smoke after diagnosis experience decreased recurrence-free survival (Fleschner et al., 1999; Stevens, Gardner, Parkin, & Johnson, 1983) and increased risk for a second primary tumor (Do et al., 2004; Johnson, 1998; Richardson et al., 1993; Tucker et al., 1997). Smoking is associated with complications in patients receiving radiation (Eifel, Jhingran, Bodurka, Levenback, & Thames, 2002; Rugg, Saunders, & Dische, 1990) and may also impact the metabolism of chemotherapy (Hamilton et al., 2006; van der Bol et al., 2007). Continuing smokers experience diminished quality of life across multiple physical, psychological, and social domains (Garces, Yang, et al., 2004) and are more likely to report higher pain scores than nonsmokers or former smokers (Daniel et al., 2009). Surgical procedures cost more and do not work as well for tobacco users because of complications such as delayed healing, wound dehiscence, and postoperative infections (Al-Sarraf et al., 2008; Kearney, Lee, Reilly, DeCamp, & Sugarbaker, 1994; Krueger & Rohrich, 2001). Given the adverse outcomes associated with continued smoking, cancer di-