A systematic review and meta-analysis of e-cigarette use among cancer survivors

PURPOSE

We conducted a systematic review and meta-analysis to determine the use of e-cigarettes among cancer survivors, factors associated with their use, and prevalence of e-cigarette use as a quit attempt.

METHODS

We searched five electronic databases until June 2022. Two authors independently selected studies, appraised their quality, and collected data.

RESULTS

Twenty-three publications from eight data sources (national surveys) met our eligibility criteria. The pooled rate of lifetime e-cigarette use among cancer survivors was 15% (95% CI 6-27%); current use was 3% (95% CI 0-8%). Among survivors who currently used traditional cigarettes, 63% (95% CI 57-69%) also used e-cigarettes. The reported rates of weighted lifetime e-cigarette use differed between age groups (18-44 years, up to 46.7%; 45-64, up to 27.2%; ≥65, up to 24.8%). Nine publications reported factors associated with lifetime e-cigarette use (i.e., active use of traditional cigarettes; heavy drinking; poor mental health; younger age; being male, non-Hispanic White, or single; having less than high school education or income ≤$25,000 USD; and living in the South regions of the US or urban areas). E-cigarettes were used as a quit resource by 75% of survivors reporting dual use of electronic and traditional cigarettes (95% CI 63%, 85%).

CONCLUSION

More than two-thirds of survivors currently using traditional cigarettes also use e-cigarettes. Higher use rates of e-cigarettes were reported among young cancer survivors compared to older survivors. Future studies are needed to assess the impact of e-cigarettes on long-term health and improve screening of smoking behaviors.

IMPLICATIONS FOR CANCER SURVIVORS

Our study provides an overview of the prevalence of e-cigarette use and sociodemographic risk factors associated with e-cigarette use among cancer survivors. The findings can assist providers in supporting attempts to quit among cancer survivors.

Continued tobacco use among tobacco-related head and neck cancer patients seeking care in a tertiary care facility, South India

INTRODUCTION

Continued tobacco use in cancer patients leads to decreased treatment efficacy and safety, decreased survival, decreased quality of life, and an increased risk of cancer recurrence and primary tumours at other sites.

OBJECTIVE

To determine the prevalence of continued tobacco usage during the first 6 months of diagnosis among tobacco-related head and neck cancer patients seeking care from a tertiary care centre and the factors associated with it.

METHODS

A facility-based cohort study was conducted at a tertiary care centre in Puducherry, India. Newly diagnosed head and neck cancer patients aged > 18 years with a history of tobacco use were interviewed to gather information on their socio-demographic, clinical characteristics, and tobacco usage. All participants were interviewed again at the 3rd month and at the 6th month during their follow-up visit. The data were entered in EpiData v3.1 and analysed using STATA v14. Multivariable logistic regression analysis was done with continued tobacco use as the dependent variable and variables that were found significantly associated with continued tobacco use in univariate analysis.

RESULTS

Out of 220 study participants at baseline, 157(71 %; 95 % CI: 65.1-77.1) were using tobacco at the time of diagnosis. Out of these 157 participants, 80(50.9 %; 95 % CI; 43.1-58.7) continued to use tobacco at the 3rd month, 63(40.1 %: 95 % CI: 32.6-47.9) continued to use tobacco at the 6th month. The characteristics significantly associated with continued tobacco use are age (less than 39 years and more than 70 years), primary school education, nuclear family, and living alone, smoking tobacco, and increased duration of tobacco use.

CONCLUSION

Two-fifths of head and neck cancer patients with a history of tobacco use continued to use tobacco at the 6th month after diagnosis of cancer. Awareness of effects of tobacco use and the benefits of tobacco cessation needs to be created among cancer patients.

Systematic review of smoking relapse rates among cancer survivors who quit at the time of cancer diagnosis

BACKGROUND

Tobacco cessation, at the time of cancer diagnosis, has been associated with better oncologic outcomes. Cancer diagnosis has been shown to serves as a "teachable moment," inspiring tobacco cessation. However, the sustainability of abstinence from smoking is understudied. Similarly, there is a paucity of data regarding the utility of behavioral/pharmacologic intervention to support continued smoking cessation.

METHODS

A systematic literature review was conducted in August 2021 with no date limits. Relevant studies that reported tobacco smoking relapse rates for patients who quit at the time of cancer diagnosis were included. Our literature search identified 1620 articles and 29 met inclusion criteria. The primary endpoint of the study was smoking relapse rate. Secondary outcome was a descriptive assessment of behavioral and pharmacologic interventions to promote continued cessation. Exploratory outcomes included a regression analysis to examine associations between study factors and relapse rates.

RESULTS

There were 3021 smokers who quit at the time of cancer diagnosis. Weighted overall relapse rate for the study population was 44 % (range 5-57 %). Interventions to support smoking cessation were employed in 17 of the 29 included studies and protocols were heterogenous, including behavioral, pharmacologic, or mixed intervention strategies. Exploratory analysis demonstrated no association between relapse rates and publication year, gender, or study type. Relapse rates were indirectly associated with age (p = .003), suggesting that younger patients were more likely to relapse.

CONCLUSION

The sustainability of smoking cessation after a cancer diagnosis is understudied, and existing literature is difficult to interpret due to heterogeneity. Relapse rates remain significant and, although many studies have included the employment of an intervention to promote continued cessation, few studies have measured the effect of a protocolized intervention to support abstinence.

Substance use and mental health burden in head and neck and other cancer survivors: A National Health Interview Survey analysis

BACKGROUND

Tobacco dependence, alcohol abuse, depression, distress, and other adverse patient-level influences are common in head and neck cancer (HNC) survivors. Their interrelatedness and precise burden in comparison with survivors of other cancers are poorly understood.

METHODS

National Health Interview Survey data from 1997 to 2016 were pooled. The prevalence of adverse patient-level influences among HNC survivors and matched survivors of other cancers were compared using descriptive statistics. Multivariable logistic regressions evaluating covariate associations with the primary study outcomes were performed. These included 1) current cigarette smoking and/or heavy alcohol use (>14 drinks per week) and 2) high mental health burden (severe psychological distress [Kessler Index ≥ 13] and/or frequent depressive/anxiety symptoms).

RESULTS

In all, 918 HNC survivors and 3672 matched survivors of other cancers were identified. Compared with other cancer survivors, more HNC survivors were current smokers and/or heavy drinkers (24.6% [95% CI, 21.5%-27.7%] vs 18.0% [95% CI, 16.6%-19.4%]) and exhibited a high mental health burden (18.6% [95% CI, 15.7%-21.5%] vs 13.0% [95% CI, 11.7%-14.3%]). In multivariable analyses, 1) a high mental health burden predicted for smoking and/or heavy drinking (odds ratio [OR], 1.4; 95% CI, 1.0-1.9), and 2) current cigarette smoking predicted for a high mental health burden (OR, 1.7; 95% CI, 1.2-2.3). Furthermore, nonpartnered marital status and uninsured/Medicaid insurance status were significantly associated with both cigarette smoking and/or heavy alcohol use (ORs, 1.9 [95% CI, 1.4-2.5] and 1.5 [95% CI, 1.0-2.1], respectively) and a high mental health burden (ORs, 1.4 [95% CI, 1.1 -1.8] and 3.0 [95% CI, 2.2-4.2], respectively).

CONCLUSIONS

Stakeholders should allocate greater supportive care resources to HNC survivors. The interdependence of substance abuse, adverse mental health symptoms, and other adverse patient-level influences requires development of novel, multimodal survivorship care interventions.

The importance of smoking status at diagnosis in human papillomavirus-associated oropharyngeal cancer

BACKGROUND

Smoking status at point of diagnosis is not used in defining risk groups for human papillomavirus (HPV)-associated oropharyngeal cancer (OPC) despite its prognostic value in head and neck cancer.

METHODS

Retrospective analysis of consecutive patients treated with chemoradiotherapy between January 2005 and July 2017 was performed with multivariable analysis to explore the impact of smoking status at diagnosis (current/former/never) on overall survival (OS), cancer-specific survival (CSS) and progression-free survival (PFS).

RESULTS

Median follow-up was 61 months. Four hundred and four patients were included. Current smokers had inferior OS versus never and former smokers [adjusted HR 2.37 (95% CI 1.26-4.45, p < 0.01) and 2.58 (95% CI 1.40-4.73, p < 0.01), respectively] and inferior PFS versus never smokers [adjusted HR 1.83 (95% CI 1.00-3.35, p = 0.04)]. Smoking status did not predict for CSS.

CONCLUSION

Detailed smoking behavior should be considered in refining risk groups in HPV-associated OPC treated with radiotherapy and in future trial design eligibility and stratification.

Exploratory study of functional and psychological factors associated with employment status in patients with head and neck cancer

BACKGROUND

Compared with other malignancies, head and neck cancer (HNC) increases the risk of not returning to work (RTW).

METHODS

Within a cross-sectional study, patients with HNC filled out the OncoFunction questionnaire, a version of the International Classification of Functioning Core Sets for HNC. In 231 patients below 65 years of age, associations of sociodemographic, clinical, functional, and psychological factors with employment and participation in rehabilitation program were explored.

RESULTS

Unemployed patients reported more swallowing difficulties and speaking problems. Being unemployed was associated with higher levels of depressive and anxiety symptoms, fatigue, and lower global health. Rehabilitation participation was not significantly associated with any of the assessed factors except for smoking.

CONCLUSIONS

Unemployed patients with HNC are more burdened than employed patients with HNC regarding clinical, psychological, and functional factors. These differences are more evident later in recovery. Rehabilitation participation was not associated with psychological and functional burden which indicates the need for tailored HNC rehabilitation programs.

Squamous cell carcinoma of head and neck: what internists should know

Squamous cell carcinoma of head and neck (SCCHN) is a group of cancer arising from mucosal surfaces of the head and neck. Optimal management of SCCHN requires a multidisciplinary team of surgical oncologists, radiation oncologists, medical oncologists, nutritionist, and speech-language pathologists, due to the complexity of anatomical structure and importance of functional outcome. Human papilloma virus (HPV)-related SCCHN represents a distinct subset from HPV negative SCCHN which is associated with carcinogen exposure such as cigarette smoking, betel nut use and alcohol. HPV related SCCHN responds better to concurrent chemoradiation and has better overall prognosis, compared to HPV negative SCCHN. Radiation therapy has been introduced to the treatment of SCCHN, administered concurrently with systemic chemotherapy for locoregional SCCHN, as well as a palliative measure for recurrent and/or metastatic (R/M) SCCHN. Recently, immune checkpoint inhibitors have been shown to improve overall survival in R/M-SCCHN and have been incorporated into the standard of care. Combination approaches with immune therapy and targeted therapy for biomarker enriched population based on genomics are being actively investigated and will shape the future of SCCHN treatment.

Associated factors with health-compromising behaviors among patients treated for oral cancer

BACKGROUND

To improve eradication strategies of health-compromising behaviors between oral cancer survivors, this study aimed to explore the extent of clustering of risk behaviors and to assess possible factors associated.

MATERIAL AND METHODS

A cross-sectional study was carried out among oral cancer patients at least 6 months after treatment. They completed a questionnaire about smoking, alcohol consumption, oral hygiene habits and dental visits. Presence of clusters was evaluated through pairwise Pearson correlations and principal component analysis. Factors associated with each identified cluster were analyzed with multivariate models.

RESULTS

Among 142 patients, 14.8% smoked, 51.7% consumed alcohol, 52.1% performed oral hygiene less than twice a day, and 74.6% visited to dentist when there was a problem or never. There were two distinct clusters: smoking-alcohol consumption (general risk behaviors cluster) and oral hygiene-dental attendance (oral risk behaviors cluster). Multivariate analysis showed significant associations between males and both clustering patterns of health compromising behaviors, patients with clinical stage I or with longer follow-up and the presence of general risk behaviors cluster and worse social class and the presence of oral risk behaviors cluster.

CONCLUSIONS

A high proportion of patients treated for oral cancer presented health-compromising behaviors occurring in clusters which reinforce the need for health promotion strategies to target multiple behaviors. Factors analyzed suggest that chances of having detrimental behavioral clustering are higher in male, patients with clinical stage I, with lower social class and those with longer follow-up after treatment.

Considerations for a head and neck smoking cessation support programme; A qualitative study of the challenges in quitting smoking after treatment for head and neck cancer

PURPOSE

Smoking is a major cause of head and neck squamous cell carcinoma (HNSCC), yet many patients who receive a diagnosis continue to smoke. This has an adverse effect on treatment and recovery, and leads to increased risks of recurrence and second cancers. There is evidence that stopping smoking after diagnosis can lead to better outcomes and reversal of risks. However, there is limited evidence for effective smoking cessation interventions in this population, and little about patient opinions regarding quitting smoking and support provided by healthcare professionals.

METHODS

This qualitative study was conducted as part of a larger project with the objective of developing a smoking cessation support programme. Eleven patients who had completed head and neck cancer (HNC) treatment were interviewed about smoking and quitting attempts. Interviews were semi-structured and took place face-to-face or over the phone.

RESULTS

Participants gave detailed accounts of their smoking journey. Thematic analysis of the data led to the identification of 2 overarching themes and four interlinking themes. Themes describe the 'guilty habit' of smoking, perceived 'barriers to quit', the 'teachable moment' of a diagnosis and the contrary 'social motivation' to both smoke and quit.

CONCLUSIONS

The results of this study highlight some missed needs for this group and major gaps in the support that is available. It is intended that the results will be used to develop a support programme for quitting smoking long term in a way that is useful and relevant to this complex population.

Pilot randomized controlled trial of a comprehensive smoking cessation intervention for patients with upper aerodigestive cancer undergoing radiotherapy

BACKGROUND

Smoking among patients with cancer is associated with poor outcomes, however, smoking cessation interventions have had limited success.

METHODS

This randomized controlled trial compared a novel smoking cessation intervention ("intervention") with enhanced usual care ("control"). Participants were smokers with head and neck or thoracic malignancies undergoing radiation. Controls received brief counseling. Intervention participants received intensive counseling, pharmacotherapy, text-messaging, and financial incentives. Biochemically confirmed 7-day abstinence at 8 weeks was compared using Fisher's exact t test. Smoking abstinence and intensity were also analyzed using time-series panel regression.

RESULTS

The study population comprised 19 intervention and 10 control participants. More intervention (74%) than control (30%) participants abstained from smoking at 8 weeks (P = .05). Intervention participants were significantly more likely to abstain (adjusted odds ratio [OR] 14.70; 95% confidence interval [CI] 3.56-60.76) and smoked fewer cigarettes (adjusted incidence rate ratio [IRR], 0.16; 95% CI 0.06-0.40) during weeks 1 to 8.

CONCLUSION

This intervention decreased smoking among patients with upper aerodigestive cancers during radiotherapy.

Indoor tanning bed use and risk of food addiction based on the modified Yale Food Addiction Scale

The popularity of indoor tanning may be partly attributed to the addictive characteristics of tanning for some individuals. We aimed to determine the association between frequent indoor tanning, which we view as a surrogate for tanning addiction, and food addiction. A total of 67,910 women were included from the Nurses’ Health Study II. In 2005, we collected information on indoor tanning during high school/college and age 25-35 years, and calculated the average use of indoor tanning during these periods. Food addiction was defined as ≥3 clinically significant symptoms plus clinically significant impairment or distress, assessed in 2009 using a modified version of the Yale Food Addiction Scale. Totally 23.3% (15,822) of the participants reported indoor tanning at high school/college or age 25-35 years. A total of 5,557 (8.2%) women met the criteria for food addiction. We observed a dose–response relationship between frequency of indoor tanning and the likelihood of food addiction (P_trend < 0.0001), independent of depression, BMI, and other confounders. Compared with never indoor tanners, the odds ratio (95% confidence interval) of food addiction was 1.07 (0.99-1.17) for average indoor tanning 1-2 times/year, 1.25 (1.09-1.43) for 3-5 times/year, 1.34 (1.14-1.56) for 6-11 times/year, 1.61 (1.35-1.91) for 12-23 times/year, and 2.98 (1.95-4.57) for 24 or more times/year. Frequent indoor tanning before or at early adulthood is associated with prevalence of food addiction at middle age. Our data support the addictive property of frequent indoor tanning, which may guide intervention strategies to curb indoor tanning and prevent skin cancer.

Changes and predictors of radiation-induced oral mucositis in patients with oral cavity cancer during active treatment

PURPOSE

Radiation-induced oral mucositis (OM) is the most debilitating side effect of radiation treatment in oral cavity cancer. The purpose of the study was to investigate change of prevalence of severe OM, OM-related symptoms, and predictors in oral cavity cancer patients during active treatment.

METHODS AND SAMPLE

Longitudinal study design with repeated measures was used. Patients with oral cavity cancer were recruited from a head and neck outpatient radiation department at a major medical center in Taiwan. Patients' OM-related symptoms were measured at three time points. Patients' oral mucosa was assessed at nine time points. Generalized estimating equations (GEE) were used to analyze the predictive factors of prevalence of severe OM and OM-related symptoms.

RESULTS

Patients reported highest prevalence of severe OM at T5 (5 weeks after beginning RT) and T6 (6 weeks after beginning radiation therapy, RT), with the combined chemotherapy and RT (CCRT) patients reporting a higher prevalence than those receiving RT alone. The peak of OM-related symptoms was at T8 (8 week after beginning RT), with primary symptoms of mouth pain, mouth dryness, eating difficulties, swallowing difficulties, and taste change. Patients with CCRT, a higher cumulative radiation dose, smoking, and lower body mass index (BMI) were at high risk to develop severe OM. OM-related symptoms were predicted by type of treatment, cumulative radiation dose, and smoking.

CONCLUSIONS

Patients with oral cavity cancer suffer from OM and OM-related symptoms during aggressive RT or CCRT. Patient-specific oral care and emotional support are needed to relieve distressful OM-related symptoms during active treatment.

Integrated psychological care in head and neck cancer: Views from health care providers, patients, and supports

OBJECTIVES/HYPOTHESIS

An evaluation by head-and-neck cancer (HNC) staff, patients, and patient support feedback regarding integrated psychological care and perceived benefit based on patient characteristics.

STUDY DESIGN

Cross-sectional survey of HNC staff, patients, and their primary supports; and retrospective chart review of psychiatric characteristics of HNC patients.

METHODS

HNC staff, patients (who were evaluated by the integrated psychologist), and their primary supports were given questionnaires on their perception of benefit of including a psychologist in the evaluation and treatment of HNC patients. Also, a retrospective chart review on patients who were psychiatrically evaluated by the psychologist on sociodemographics and psychiatric characteristics.

RESULTS

Overall, integration of a psychologist was well received by patients, supports, and staff. Younger patients reported greater satisfaction with the availability of the psychologist than older patients (P = .04), and patients with reported psychiatric histories (diagnoses in remission) indicated more satisfaction with the psychologist in relation to managing distress than patients who denied psychiatric histories (P = .03); however, patients who were currently smoking tended to report lower satisfaction with the psychologist helping with distress than those who were past/never smokers (P = .06).

CONCLUSIONS

Integrated psychological care has the potential to improve care provided for HNC patients.

LEVEL OF EVIDENCE

Level 4.