There is a high incidence of tobacco use among patients with cancer. Many are unable to quit smoking before cancer surgery, and relapse rates are high among those who are able to abstain after the initial cancer diagnosis. Tobacco use is linked to serious complications with treatment, including increased problems with wound healing and respiratory complications. Contingency management, a behavioral intervention in which abstinence is directly reinforced (typically with monetary rewards), has shown promise as an intervention for smoking. In our preliminary work, we designed a contingency management protocol for pre-surgical cancer patients, and conducted 10 interviews with past patients to obtain opinions on the proposed plan. Patients were unanimous in their interest in participating in this program and felt monetary rewards would provide motivation and accountability. Subsequently, we conducted a small, pre-surgical smoking cessation pilot study in which patients were randomized to receive either standard care (SC;3-6 counseling sessions + Nicotine Replacement Therapy [NRT]) or standard care plus contingency management (CM;counseling sessions + NRT + monetary payment delivered contingent on abstinence). Results from our preliminary pilot study (N=8) demonstrated that patients who received CM had higher rates of abstinence prior to surgery compared to a group receiving only SC. Three of 4 participants (75%) in the CM arm of the study were abstinent prior to surgery as compared to 1 of 4 participants (25%) who were abstinent in the SC arm. Two of 4 participants (50%) in the CM arm of the study were abstinent at the 3-month follow-up as compared to 1 of 4 participants (25%) who were abstinent in the SC arm. The sample size from this pilot study is too small for inferential testing, but these data are promising and suggest a treatment effect. Further, this pilot study demonstrated the feasibility and preliminary efficacy of this approach. The proposed study will constitute a larger (N=40), developmental interdisciplinary pilot clinical trial evaluatng the effects of the CM intervention compared to an SC group with presurgical cancer patients. The primary aim of the proposed study is to develop an effect size for smoking cessation at the time of surgery (7-day point prevalence), with a secondary aim of creating an effect size for long-term abstinence at 3 months post-surgery. We will also examine exploratory outcomes of perioperative complications and rates of continuous abstinence.
Studying interventions for smokers prior to cancer surgery has the potential to improve quit rates as well as surgical outcomes in this population. We hypothesize that this pre-surgical intervention, combining smoking cessation counseling and nicotine replacement therapy (NRT) with contingency management, will promote high rates of smoking cessation and will be associated with better surgical and post-operative outcomes.