Portal de Periódicos da CAPES

Smoking Cessation in Cancer Care: Myths, Presumptions and Implications for Practice

2020; Elsevier BV; Volume: 32; Issue: 6 Linguagem: Inglês

10.1016/j.clon.2020.01.008

1433-2981

Meredith Giuliani, Janette Brual, Erin Cameron, Michael Chaiton, Lawson Eng, M. Haque, Geoffrey Liu, Nicole Mittmann, Janet Papadakos, Deborah Saunders, Rebecca Truscott, William K. Evans,

Lung Cancer Research Studies

Continued tobacco use adversely affects cancer treatment outcomes. Specifically, continued smoking by cancer patients can accelerate disease progression, result in decreased overall and disease-specific survival, as well as increase the risk of disease recurrence and developing second cancers [[1]Richardson G.E. Tucker M.A. Venzon D.J. Linnoila R.I. Phelps R. Phares J.C. et al.Smoking cessation after successful treatment of small-cell lung cancer is associated with fewer smoking-related second primary cancers.Ann Intern Med. 1993; 119: 383-390Crossref PubMed Scopus (210) Google Scholar]. Smoking can also result in an increased risk of surgical complications, including infections, poor wound healing and pulmonary complications [[2]Kuri M. Nakagawa M. Tanaka H. Hasuo S. Kishi Y. Determination of the duration of preoperative smoking cessation to improve wound healing after head and neck surgery.Anesthesiology. 2005; 102: 892-896Crossref PubMed Scopus (146) Google Scholar,[3]Cataldo J.K. Dubey S. Prochaska J.J. Smoking cessation: an integral part of lung cancer treatment.Oncology. 2010; 78: 289-301Crossref PubMed Scopus (134) Google Scholar]. Continued smoking while receiving radiation therapy can increase risks of side-effects, reduce the chances of a complete response to radiation treatment and shorten survival [[4]Chen A.M. Chen L.M. Vaughan A. Sreeraman R. Farwell D.G. Luu Q. et al.Tobacco smoking during radiation therapy for head-and-neck cancer is associated with unfavorable outcome.Int J Radiat Oncol Biol Phys. 2011; 79: 414-419Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar]. During chemotherapy, smoking can result in reduced treatment efficacy and exacerbate side-effects [[5]van der Bol J.M. Mathijssen R.H. Loos W.J. Friberg L.E. van Schaik R.H. de Jonge M.J. et al.Cigarette smoking and irinotecan treatment: pharmacokinetic interaction and effects on neutropenia.J Clin Oncol. 2007; 25: 2719-2726Crossref PubMed Scopus (114) Google Scholar,[6]Keizman D. Gottfried M. Ish-Shalom M. Maimon N. Peer A. Neumann A. et al.Active smoking may negatively affect response rate, progression-free survival, and overall survival of patients with metastatic renal cell carcinoma treated with sunitinib.Oncologist. 2014; 19: 51-60Crossref PubMed Scopus (47) Google Scholar]. Despite these adverse effects, about 20% of cancer patients report that they currently use tobacco, even after a diagnosis of cancer [[7]Karam-Hage M. Cinciripini P.M. Gritz E.R. Tobacco use and cessation for cancer survivors: an overview for clinicians.CA Cancer J Clin. 2014; 64: 272-290Crossref PubMed Scopus (84) Google Scholar,[8]Coups E.J. Ostroff J.S. A population-based estimate of the prevalence of behavioral risk factors among adult cancer survivors and noncancer controls.Prev Med. 2005; 40: 702-711Crossref PubMed Scopus (306) Google Scholar]. Patients and healthcare providers (HCPs) may hold beliefs that are not factually based about the value and importance of smoking cessation in the oncology setting and can make misguided and misinformed decisions that can affect cancer management. These beliefs or myths, are persistent, potentially harmful, increase fear among the public and are difficult to dispel, despite the abundance of scientific evidence that proves otherwise [[9]Carlsson M.E. Strang P.M. Facts, misconceptions, and myths about cancer.Gynecol Oncol. 1997; 65: 46-53Abstract Full Text PDF PubMed Scopus (21) Google Scholar]. Although low health literacy may contribute to poor adherence to smoking cessation interventions [[10]Stewart D.W. Adams C.E. Cano M.A. Correa-Fernández V. Li Y. Waters A.J. et al.Associations between health literacy and established predictors of smoking cessation.Am J Publ Health. 2013; 103: e43-e49Crossref PubMed Scopus (89) Google Scholar], myths about smoking and cancer diagnoses influence how patients and HCPs view the role of smoking cessation in cancer care [[9]Carlsson M.E. Strang P.M. Facts, misconceptions, and myths about cancer.Gynecol Oncol. 1997; 65: 46-53Abstract Full Text PDF PubMed Scopus (21) Google Scholar]. Leading North American oncology groups [11Cancer Care Ontario Smoking cessation information for healthcare providers.2018https://www.cancercareontario.ca/en/guidelines-advice/cancer-continuum/prevention/smoking-cessationGoogle Scholar, 12Canadian Partnership Against Cancer CorporationLeading practices in clinical smoking cessation.https://www.partnershipagainstcancer.ca/topics/leading-practices-clinical-smoking-cessation/Date: 2019Google Scholar, 13American society of clinical oncology tobacco cessation guide: for oncology providers. American Society of Clinical Oncology, Alexandria, VA2012Google Scholar, 14National Comprehensive Cancer Network NCCN clinical practice guidelines in oncology (NCCN guidelines) smoking cessation version 1.2018. National Comprehensive Cancer Network, 2018Google Scholar] have advocated that smoking cessation become a standard in cancer care, emphasising the critical role that HCPs play in assisting patients to quit. However, there is a mismatch between HCPs' actions related to smoking cessation and their knowledge of the benefits of smoking cessation for cancer patients [[15]Keto J. Jokelainen J. Timonen M. Linden K. Ylisaukko-oja T. Physicians discuss the risks of smoking with their patients, but seldom offer practical cessation support.Subst Abuse Treat Prev Pol. 2015; 10: 43Crossref PubMed Scopus (25) Google Scholar]. Smoking cessation interventions are not well integrated into routine cancer care and significant barriers prevent patients from accessing cessation services. A leadership forum consisting of clinicians, policymakers and researchers, including designated smoking cessation champions from regional cancer centres in Ontario, identified common myths about smoking cessation in cancer care. We present the top five myths and provide evidence from the literature to debunk each myth. The clinical implications of these myths are summarised and recommendations to move past these myths are proposed (see Table 1).Table 1Five myths and the presumptions around smoking cessation in cancer and the practice implications for cancer careMythPresumptions and conjecturesTruthImplications for practiceRecommendationsMyth #1: It is too late to quit once someone already has cancerBased on the belief that once a patient is diagnosed with cancer, smoking-related or not, the damage has already been done and quitting smoking will not have any further impact on their health and disease.Smoking cessation is viewed as an adjunct to treatment or as supportive care rather than a form of treatment itself.Abstaining from smoking during and after treatment is a strong predictor of survival among patients who are current smokers or have a history of smoking [[7]Karam-Hage M. Cinciripini P.M. Gritz E.R. Tobacco use and cessation for cancer survivors: an overview for clinicians.CA Cancer J Clin. 2014; 64: 272-290Crossref PubMed Scopus (84) Google Scholar].Smoking cessation is linked to reductions in treatment-related complications and toxicities [[2]Kuri M. Nakagawa M. Tanaka H. Hasuo S. Kishi Y. Determination of the duration of preoperative smoking cessation to improve wound healing after head and neck surgery.Anesthesiology. 2005; 102: 892-896Crossref PubMed Scopus (146) Google Scholar,[3]Cataldo J.K. Dubey S. Prochaska J.J. Smoking cessation: an integral part of lung cancer treatment.Oncology. 2010; 78: 289-301Crossref PubMed Scopus (134) Google Scholar], better treatment outcomes [[4]Chen A.M. Chen L.M. Vaughan A. Sreeraman R. Farwell D.G. Luu Q. et al.Tobacco smoking during radiation therapy for head-and-neck cancer is associated with unfavorable outcome.Int J Radiat Oncol Biol Phys. 2011; 79: 414-419Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar] and improved quality of life [[1]Richardson G.E. Tucker M.A. Venzon D.J. Linnoila R.I. Phelps R. Phares J.C. et al.Smoking cessation after successful treatment of small-cell lung cancer is associated with fewer smoking-related second primary cancers.Ann Intern Med. 1993; 119: 383-390Crossref PubMed Scopus (210) Google Scholar,[16]Gritz E.R. Fingeret M.C. Vidrine D.J. Lazev A.B. Mehta N.V. Reece G.P. Successes and failures of the teachable moment: smoking cessation in cancer patients.Cancer. 2006; 106: 17-27Crossref PubMed Scopus (292) Google Scholar]. More benefits include improving prognostic outcomes [[17]Parsons A. Daley A. Begh R. Aveyard P. Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis.BMJ. 2010; 340b5569Crossref PubMed Scopus (541) Google Scholar], including survival and a lowered risk for secondary cancers [[1]Richardson G.E. Tucker M.A. Venzon D.J. Linnoila R.I. Phelps R. Phares J.C. et al.Smoking cessation after successful treatment of small-cell lung cancer is associated with fewer smoking-related second primary cancers.Ann Intern Med. 1993; 119: 383-390Crossref PubMed Scopus (210) Google Scholar].These benefits are probably underestimated as studies that examined the association between smoking and cancer outcomes used assessments that are non-standardised [[7]Karam-Hage M. Cinciripini P.M. Gritz E.R. Tobacco use and cessation for cancer survivors: an overview for clinicians.CA Cancer J Clin. 2014; 64: 272-290Crossref PubMed Scopus (84) Google Scholar,[18]Gritz E.R. Toll B.A. Warren G.W. Tobacco use in the oncology setting: advancing clinical practice and research.Cancer Epidemiol Prev Biomarkers. 2014; 23: 3-9Crossref PubMed Scopus (78) Google Scholar].Patients who continue to smoke will experience poorer treatment outcomes when compared with non-smokers or patients who quit.All cancer patients should be screened for tobacco use and assisted with cessation if using tobacco products.The benefits of cessation should be discussed with cancer patients and survivors who have ever smoked.Healthcare providers should receive core training in the benefits of smoking cessation for patients with cancer [[19]Pbert L. Healthcare provider training in tobacco treatment: building competency.Am J Med Sci. 2003; 326: 242-247Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar].Brief targeted training can increase healthcare providers' motivation, self-efficacy and preparedness to engage with cancer patients on smoking cessation [[20]Sheffer C.E. Barone C.P. Anders M.E. Training health care providers in the treatment of tobacco use and dependence: pre-and post-training results.J Eval Clin Pract. 2009; 15: 607-613Crossref PubMed Scopus (46) Google Scholar].Myth #2: The time of diagnosis is not the right time to address smoking cessationBased on the notion that patients dealing with a new cancer diagnosis can be overwhelmed, unwell and anxious.Healthcare providers may fear further burdening patients who are already overwhelmed about their diagnosis, treatment options and prognosis.Healthcare providers also fear that discussing cessation may have a negative impact on their relationship with patients because of the stigma associated with smoking.Patients who continue to smoke may not understand that continued smoking can worsen their cancer condition, or affect long-term treatment or recovery, even non-curative treatment in a palliative setting.Acceptance of a smoking cessation intervention can be greatly influenced by a physician's recommendation to quit [[21]Webb A.R. Robertson N. Sparrow M. Smokers know little of their increased surgical risks and may quit on surgical advice.ANZ J Surg. 2013; 83: 753-757PubMed Google Scholar].In some cases, appealing to patients and their families regarding the dangers of exposure to second-hand smoke can be effective [[22]Eng L. Su J. Qiu X. Palepu P.R. Hon H. Fadhel E. et al.Second-hand smoke as a predictor of smoking cessation among lung cancer survivors.J Clin Oncol. 2014; 32: 564-570Crossref PubMed Scopus (57) Google Scholar].Healthcare providers miss a valuable opportunity to educate patients about cessation and optimise their treatment and survival.Quitting smoking takes effort and by not engaging with patients early and continually throughout their treatment, discussions about cessation are not normalised as a standard of cancer care.Advise all cancer patients with a history of tobacco use about the harms of smoking and the benefits of cessation.Engage patients' social networks by including family members and caregivers to aid in smoking cessation interventions and improve quit rates [[23]Bastian L.A. Fish L.J. Peterson B.L. Biddle A.K. Garst J. Lyna P. et al.Proactive recruitment of cancer patients' social networks into a smoking cessation trial.Contemp Clin Trial. 2011; 32: 498-504Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar].Healthcare providers should discuss the importance of cessation with family members, both smokers and non-smokers, included. This is particularly important at the time of diagnosis where motivation for health behaviour change is high and both patients and family members may be more open to lifestyle interventions [[24]Ozakinci G. Wells M. Williams B. Munro A.J. Donnelly P. Cancer diagnosis: an opportune time to help patients and their families stop smoking?.Public Health. 2010; 124: 479-482Crossref PubMed Scopus (9) Google Scholar].Myth #3: Cancer patients are not interested in quitting smokingBased on the belief that patients may have feelings of guilt about smoking after receiving a cancer diagnosis, have fatalistic thoughts or knowledge avoidance about smoking cessation, and may not initiate a discussion with their healthcare provider, thereby giving the appearance that the patient is not interested in quitting.Patients themselves may also hold certain beliefs with respect to their own ability to quit smoking, including previous unsuccessful quit attempts, which in turn may be reinforced by healthcare providers' lack of intervention and education about the harms of smoking.Literature suggests that although many healthcare providers are effective in identifying and educating patients about the harms of continued smoking, they may not do enough to support them to actually quit [[15]Keto J. Jokelainen J. Timonen M. Linden K. Ylisaukko-oja T. Physicians discuss the risks of smoking with their patients, but seldom offer practical cessation support.Subst Abuse Treat Prev Pol. 2015; 10: 43Crossref PubMed Scopus (25) Google Scholar], which may be hindered by certain myths and misconceptions.Patients may feel stigmatised by their own smoking behaviour and may be uncomfortable discussing it with their oncologist or avoid the topic entirely.Screen all cancer patients for smoking status as routine care. This normalises the practice for healthcare providers.Having an open conversation about smoking cessation and providing education as well as support is the only way to determine a patient's interest in quitting. Patients may not be aware of the benefits of cessation, or the harms of continued smoking, and this lack of awareness should not be mistaken for lack of interest [[25]Alton D. Eng L. Lu L. Song Y. Su J. Farzanfar D. et al.Perceptions of continued smoking and smoking cessation among patients with cancer.J Oncol Pract. 2018; 14: e269-e279Crossref PubMed Scopus (24) Google Scholar].Myth #4: My patient is incurable; there is no role for smoking cessationBased on the belief that for patients who are terminal, quitting smoking has no added benefit for palliative care or symptoms control.The notion that smoking or tobacco use may be a routine habit and form of stress relief or concerns about adding symptoms of nicotine withdrawal to a patient with cancer-related symptoms.A systematic review and meta-analysis of 26 studies of adult smokers in the general population found that quitting was associated with greater reductions in stress than with continued smoking [[26]Taylor G. McNeill A. Girling A. Farley A. Lindson-Hawley N. Aveyard P. Change in mental health after smoking cessation: systematic review and meta-analysis.BMJ. 2014; 348g1151Crossref PubMed Scopus (614) Google Scholar].Patients who continue to smoke after diagnosis report more severe pain than those who have never smoked [[27]Daniel M. Keefe F.J. Lyna P. Peterson B. Garst J. Kelley M. et al.Persistent smoking after a diagnosis of lung cancer is associated with higher reported pain levels.J Pain. 2009; 10: 323-328Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar], and greater pain-related functional impairment [[28]Ditre J.W. Gonzalez B.D. Simmons V.N. Faul L.A. Brandon T.H. Jacobsen P.B. Associations between pain and current smoking status among cancer patients.Pain. 2011; 152: 60-65Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar].Advanced stage or terminal cancer patients may be prescribed oxygen therapy for the palliation of breathlessness [[29]Booth S. Wade R. Oxygen or air for palliation of breathlessness in advanced cancer.J R Soc Med. 2003; 96: 215-218Crossref PubMed Google Scholar] and important safety considerations include burns, inhalation injuries and risks of fire or explosions that could provide further rationale for a patient to quit [[30]Litt E.J. Ziesche R. Happak W. Lumenta D.B. Burning HOT: revisiting guidelines associated with home oxygen therapy.Int J Burns Trauma. 2012; 2: 167-170PubMed Google Scholar].Patients who continue to smoke in the late, incurable stage will experience worsened symptoms and poorer quality of life.Screen and advise all patients regardless of diagnosis or prognosis.Incorporate a routine tobacco use history into assessments for symptoms control.Myth #5: It is not my job as an oncology practitioner/physician to address smoking cessationBased on the belief that smoking status should be assessed and cessation efforts should be addressed in other specialties, including primary care or addiction specialists, rather than during cancer care and treatment.Many oncology healthcare providers may feel that discussing smoking status and cessation counselling can only be done by a smoking cessation specialist or primary care provider.Oncology healthcare providers are well positioned to provide information to patients and facilitate referral to a specialised cessation service [[31]Sarna L. Wewers M.E. Brown J.K. Lillington L. Brecht M.L. Barriers to tobacco cessation in clinical practice: report from a national survey of oncology nurses.Nurs Outlook. 2001; 49: 166-172Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar]. Offering assistance motivates a greater number of quit attempts than offering advice to quit on medical grounds [[32]Aveyard P. Begh R. Parsons A. West R. Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance.Addiction. 2012; 107: 1066-1073Crossref PubMed Scopus (249) Google Scholar].Discussions about smoking cessation are not initiated by oncologist healthcare providers as a standard of cancer care and may further stigmatise cancer patients who continue to smoke.Routine, standardised assessment and support for smoking cessation requires a brief and efficient assessment of smoking status and messaging on the health benefits of smoking cessation in the context of cancer treatment.Improving patient–provider engagement in smoking cessation education and referrals includes increasing provider education, improving access to and understanding of available smoking cessation services, and leveraging cancer patient social support and networks [[32]Aveyard P. Begh R. Parsons A. West R. Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance.Addiction. 2012; 107: 1066-1073Crossref PubMed Scopus (249) Google Scholar]. Open table in a new tab Patients and HCPs may believe that there are no benefits to smoking cessation once there is a cancer diagnosis. This belief may be reinforced by low confidence in a patient's motivation to quit and concerns about patient resistance in discussing cessation. Overcoming patients' perceptions about quitting or myths about continued smoking can be a considerable challenge, particularly if HCPs feel ill equipped to provide counselling and pharmacotherapy services [[33]Quaife S. McEwen A. Janes S. Wardle J. Smoking is associated with pessimistic and avoidant beliefs about cancer: results from the International Cancer Benchmarking Partnership.Br J Cancer. 2015; 112: 1799Crossref PubMed Scopus (30) Google Scholar]. In addition, HCPs may underestimate the risks of continued smoking [[25]Alton D. Eng L. Lu L. Song Y. Su J. Farzanfar D. et al.Perceptions of continued smoking and smoking cessation among patients with cancer.J Oncol Pract. 2018; 14: e269-e279Crossref PubMed Scopus (24) Google Scholar] and/or lack of knowledge about the benefits of quitting for patients. A cancer diagnosis can serve as a 'teachable moment' to motivate patients to quit smoking. One study showed that patients who had a history of multi-drug use or a long-time dependence on nicotine were receptive to smoking cessation at the time of diagnosis, particularly when cessation services were initiated, structured and led by an HCP [[34]Sharp L. Johansson H. Fagerström K. Rutqvist L. Smoking cessation among patients with head and neck cancer: cancer as a 'teachable moment'.Eur J Cancer Care. 2008; 17: 114-119Crossref PubMed Scopus (40) Google Scholar]. However, HCPs rarely use this opportunity to discuss cessation, which can be an ideal time to discuss cessation in terms of optimising treatment and survival. For instance, head and neck cancer survivors reported high quit rates (74%) during radiation treatment, with most remaining smoke-free (68%) within the first year from diagnosis [[22]Eng L. Su J. Qiu X. Palepu P.R. Hon H. Fadhel E. et al.Second-hand smoke as a predictor of smoking cessation among lung cancer survivors.J Clin Oncol. 2014; 32: 564-570Crossref PubMed Scopus (57) Google Scholar]. Another study also found long-term cessation after 1 year from diagnosis [[35]Gritz E.R. Carr C.R. Rapkin D. Abemayor E. Chang L.J. Wong W.K. et al.Predictors of long-term smoking cessation in head and neck cancer patients.Cancer Epidemiol Biomarkers Prev. 1993; 2: 261-270PubMed Google Scholar], highlighting the importance of intervention across all phases of the cancer journey, and the central role HCPs have in introducing smoking cessation and providing ongoing support to prevent relapse. After a cancer diagnosis, patients may be more open to discussing their perceptions of risk or those of family members [[25]Alton D. Eng L. Lu L. Song Y. Su J. Farzanfar D. et al.Perceptions of continued smoking and smoking cessation among patients with cancer.J Oncol Pract. 2018; 14: e269-e279Crossref PubMed Scopus (24) Google Scholar,[36]McBride C.M. Ostroff J.S. Teachable moments for promoting smoking cessation: the context of cancer care and survivorship.Cancer Contr. 2003; 10: 325-333Crossref PubMed Scopus (190) Google Scholar], which provides an opportunity to discuss their health behaviours in relation to the seriousness of their cancer diagnosis. HCPs may make presumptions about a patient's ability or willingness to quit, believing that a patient who does not bring up their tobacco use status may not be interested in quitting, but low patient motivation is not necessarily a barrier to quitting [[37]Pisinger C. Vestbo J. Borch-Johnsen K. Jørgensen T. It is possible to help smokers in early motivational stages to quit: the Inter99 study.Prev Med. 2005; 40: 278-284Crossref PubMed Google Scholar]. A significant challenge faced by HCPs in cancer care is the moral obligation to care for a patient and the potential encroachment on patient rights by recommending a tobacco intervention. However, patients may not be aware of the benefits of quitting or may feel stigmatised by their smoking that they avoid discussing this with their oncologist. Empathy and not wanting to overwhelm cancer patients are among the reasons HCPs may feel that there is no role for cessation in advanced cancer or in the palliative setting. HCPs may view smoking as a coping mechanism for cancer patients during treatment or help in managing pain [[38]Ditre J.W. Brandon T.H. Pain as a motivator of smoking: effects of pain induction on smoking urge and behavior.J Abnorm Psychol. 2008; 117: 467Crossref PubMed Scopus (134) Google Scholar]. Patients and HCPs may also believe that smoking helps reduce stress or offers other mental health benefits [[26]Taylor G. McNeill A. Girling A. Farley A. Lindson-Hawley N. Aveyard P. Change in mental health after smoking cessation: systematic review and meta-analysis.BMJ. 2014; 348g1151Crossref PubMed Scopus (614) Google Scholar,[39]McDermott M.S. Marteau T.M. Hollands G.J. Hankins M. Aveyard P. Change in anxiety following successful and unsuccessful attempts at smoking cessation: cohort study.Br J Psychiatr. 2013; 202: 62-67Crossref PubMed Scopus (69) Google Scholar], but there are practical and clinical reasons why smoking cessation is beneficial, even during late-stage palliative care. Patients with incurable disease may be offered palliative treatments, and as with any anticancer treatment, quitting smoking can improve efficacy or lessen the toxicity of these systemic and targeted therapies. There are clear benefits of smoking cessation at any stage and any treatment, whether curative or palliative, and should be part of supportive care management. HCPs may actively inquire about the smoking behaviours of their patients and advise them to quit, but less frequently refer patients to cessation services or provide support directly [[15]Keto J. Jokelainen J. Timonen M. Linden K. Ylisaukko-oja T. Physicians discuss the risks of smoking with their patients, but seldom offer practical cessation support.Subst Abuse Treat Prev Pol. 2015; 10: 43Crossref PubMed Scopus (25) Google Scholar,[40]Weaver K.E. Danhauer S.C. Tooze J.A. Blackstock A.W. Spangler J. Thomas L. et al.Smoking cessation counseling beliefs and behaviors of outpatient oncology providers.Oncologist. 2012; 17: 455-462Crossref PubMed Scopus (60) Google Scholar]. They may be aware of the benefits of smoking cessation in cancer, but may not consider it as important as other components of their cancer care. The reasons preventing HCPs from offering smoking cessation support are related to time, lack of training or knowledge about where to refer patients [[41]Cooley M.E. Lundin R. Murray L. Smoking cessation interventions in cancer care: opportunities for oncology nurses and nurse scientists.Ann Rev Nurs Res. 2009; 27: 243Crossref PubMed Scopus (36) Google Scholar,[42]Conlon K. Pattinson L. Hutton D. Attitudes of oncology healthcare practitioners towards smoking cessation: a systematic review of the facilitators, barriers and recommendations for delivery of advice and support to cancer patients.Radiography. 2017; 23: 256-263Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar] and having low confidence in their abilities to counsel patients [[40]Weaver K.E. Danhauer S.C. Tooze J.A. Blackstock A.W. Spangler J. Thomas L. et al.Smoking cessation counseling beliefs and behaviors of outpatient oncology providers.Oncologist. 2012; 17: 455-462Crossref PubMed Scopus (60) Google Scholar]. HCPs may feel that addressing their patient's smoking means having to take on the responsibility for answering questions about smoking cessation or to provide services with which they are unfamiliar [[43]Duffy S.A. Louzon S.A. Gritz E.R. Why do cancer patients smoke and what can providers do about it?.Commun Oncol. 2012; 9: 344Crossref PubMed Scopus (35) Google Scholar,[44]Mazza R. Lina M. Boffi R. Invernizzi G. De Marco C. Pierotti M. Taking care of smoker cancer patients: a review and some recommendations.Ann Oncol. 2010; 21: 1404-1409Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar]. However, HCPs need not be experts in smoking cessation and they can provide patients with referrals to specialised services, where they can receive ongoing support. There is ample evidence to support the benefits of smoking cessation before, during and after cancer treatment. Smoking cessation has a critical and hugely important role in improving patient outcomes in cancer care. Quit rates tend to be higher among cancer patients who receive an intervention versus those who receive usual care [[35]Gritz E.R. Carr C.R. Rapkin D. Abemayor E. Chang L.J. Wong W.K. et al.Predictors of long-term smoking cessation in head and neck cancer patients.Cancer Epidemiol Biomarkers Prev. 1993; 2: 261-270PubMed Google Scholar]. Quit rates may vary for cancer patients, but research suggests that it is never too late to discuss cessation [[45]McCarter K. Martínez Ú. Britton B. Baker A. Bonevski B. Carter G. et al.Smoking cessation care among patients with head and neck cancer: a systematic review.BMJ Open. 2016; 6e012296Crossref PubMed Scopus (36) Google Scholar]. In time-to-quitting analyses, one study of lung cancer patients found that 68% of smokers had quit within 6 months of the initial diagnosis, with an overall quit rate of 74% over an average follow-up time of 54 months [[22]Eng L. Su J. Qiu X. Palepu P.R. Hon H. Fadhel E. et al.Second-hand smoke as a predictor of smoking cessation among lung cancer survivors.J Clin Oncol. 2014; 32: 564-570Crossref PubMed Scopus (57) Google Scholar]. Additionally, a cancer diagnosis can be an opportunity for primary, secondary or tertiary prevention for the patient's family members, which can be a positive experience for cancer patients. The common myths discussed herein have important implications for cancer patients. Recommendations to improve smoking cessation efforts include increasing physician engagement, overcoming cost barriers for interventions such as nicotine replacement therapy, standardising screening practices and addressing the lack of resources to provide in-house cessation support [[46]Evans W.K. Truscott R. Cameron E. Peter A. Reid R. Selby P. et al.Lessons learned implementing a province-wide smoking cessation initiative in Ontario's cancer centres.Curr Oncol. 2017; 24: e185-e190Crossref PubMed Google Scholar]. However, it is important to recognise the harmful ways in which certain myths influence HCPs' willingness and likelihood to provide advice on smoking cessation and referral to services. We strongly advocate for normalising conversations about smoking cessation in the oncology setting, to make screening for smoking status a standard in care and to establish routine referral of all cancer patients who smoke to an appropriate smoking cessation service. However, this is contingent on open patient–provider communication supported by evidence to guide patients in making the best decisions for their cancer treatment. As patients generally rely on their HCPs to initiate conversations about smoking cessation, HCPs require appropriate training and education about the benefits of smoking cessation. Greater knowledge about both the value of smoking cessation and the ease of providing a referral for cessation services can motivate HCPs to be more active in referring their patients to smoking cessation services [[47]Azuri J. Nashef S. Primary care physicians' characteristics and attitudes on smoking cessation.Am J Health Behav. 2016; 40: 578-584Crossref PubMed Scopus (3) Google Scholar]. Tailored approaches in education provided to patients may also improve cessation efforts before and during treatment [[48]Warren G.W. Marshall J.R. Cummings K.M. Toll B. Gritz E.R. Hutson A. et al.Practice patterns and perceptions of thoracic oncology providers on tobacco use and cessation in cancer patients.J Thorac Oncol. 2013; 8: 543-548Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar,[49]Giuliani M. Brual J. Eng L. Liu G. Papadakos C.T. Papadakos J. Investigating the smoking cessation informational needs of cancer patients and informal caregivers.J Cancer Educ. 2019; https://doi.org/10.1007/s13187-019-01547-wCrossref Scopus (2) Google Scholar]. It is essential that given the constraints on HCPs' time and heavy workloads in the increasingly complex cancer care environment, every effort should be made to make the process of advising and referring to specialised services as efficient as possible. The authors report no conflicts of interest.n. M. Chaiton was supported with a grant from the Ontario Ministry of Health and Long Term Care and M. Giuliani was supported with a grant from Eli Lilly, and is on the advisory board with AstraZeneca and Bristol-Myers Squibb. No other authors report any relevant conflict of interests relating to this manuscript. The authors confirm that any financial support or other relationships during the development of this manuscript did not influence or bias any decisions made to the conception, design, execution and manuscript preparation.