Smoking Is an Independent Marker of Poor Prognosis in Cutaneous Melanoma

Smoking. I was never a smoker, so it is easy for me to suggest that my patients should not smoke. This article about the lower survival of melanoma patients who smoke is one of hundreds of similar articles that make this case. However, I admit to failing to take 30 seconds to refer my smoking patients to a free "quit line," which appears in my EPIC notes with one click. Why? I admit to being frustrated by a low likelihood of success, dirty looks, and sometimes outright hostility that flows from a helpful comment about the hazards of smoking. I know that I need to do better for my patients. What if 1 in 100 needed one more suggestion to finally quit? I plan to start today with the question, "Have you ever thought about quitting smoking?" I'll let you know how it works!

As dermatologists we preach "sunscreens" and "look for changing lesions" as ways to prevent skin cancers and identify malignant lesions sooner. But, encouraging people to quit smoking cigarettes is associated with much more risk reduction in terms of morbidity and mortality on a population basis. This study on melanoma survival risk is just one more reason to pay attention to this detail.

I find I'm pretty good about engaging with patients on the topic, as I believe there are data to support "each time you quit, you have a higher chance of quitting for good." If I'm wrong, then this is one area where I'm not going to worry about a randomized trial...changing habits, especially when there is a chemical dependency associated, can be very difficult, and I'm going with motivation wherever I can find it. Here are my usual lines, not always in this order, in case you want to adopt some version of these to your practice:

• So when are you going to quit smoking?

• if the answer is "never," then hopefully they really enjoy it.

• if the answer is I've tried, then I share my "data" about the benefits of trying again.

• I make the question light and say things like, "why don't we pick a date to quit?" and "I love April FOOLS day, because we DO know it's a bit foolish to smoke" (although, any easy-to-remember date coming up like Memorial Day, Labor Day, a birthday, etc would work as well).

• if they tell me they need help, I provide whatever they need, although I don't generally prescribe medications except for those patients who I know quite well and use me (albeit inappropriately) as the only physician they see. I am a big believer in directing all patients to a primary care provider who can coordinate access for programs and medications for any motivated patient.

Here's the great news....since I've taken a lighter approach to it, every year I get several people who come back and thank me....somehow I was the tipping point of conversation. It only takes a few seconds, and, if I'm rebuffed, I let it go and move on.