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Comment & Response
July 25, 2019

The Use of e-Cigarettes in Patients With Cancer—A Double Shipwreck

Author Affiliations
  • 1University Hospital, Amiens, France
JAMA Oncol. 2019;5(9):1371. doi:10.1001/jamaoncol.2019.2384

To the Editor Sanford and colleagues1 must be commended for confirming that the conventional smoking prevalence plateau, which is more than 50%, demonstrates that e-cigarette use is an epidemic in patients with cancer.

First, the smoking prevalence finding is not surprising. Only 75% of oncologists assess tobacco use at the intake visit, 60% advise patients to quit, and substantially fewer clinicians recommend cessation treatment despite the fact that smoking seriously affects outcomes (eg, cancer treatment effectiveness, overall survival, risk of second primary malignant neoplasms, quality of life).2 The five steps of intervention (ie, the “5As”) seems designed to fail! “Advising users to quit” is naive; tobacco is among the most addictive products, and of smokers who have made serial cessation attempts, most have failed. Why assess their willingness to quit when no one expects them to be able to quit? Moreover, could the cancer diagnosis visit be the propitious moment for planning cessation? Smokers deserve reassurance and proactive treatment by a specialist who can provide motivational interviewing and psychological support, which requires time, skill, and monitoring of the “belt and braces” strategy that combines nicotine patches with oral “rescue” formulations of nicotine (sprays and lozenges) to suppress occasional cravings. Nicotine doses must be increased without fear until cravings are suppressed.3 Smokers must be reassured because most of them are more scared of nicotine than of carbon monoxide or tar and/or wrongly believe that smoking with patches is more dangerous than smoking without them, overlooking the devastating effects of compensatory uptake when trying to reduce smoking without patches. Do not simply ask the smoker to quit, but encourage the smoker to adhere to treatment and increase nicotine doses as needed to address the pain and suffering of cravings. The motto must be to hasten slowly!

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