Prevalence and factors related to smoking and smoking cessation 6 months following a cancer diagnosis: a population-based study

Effective Timing of Introducing an Inpatient Smoking Cessation Program to Cancer Patients

PURPOSE

We aimed to identify factors influencing smoking cessation success among cancer patients registered in an inpatient smoking cessation program at a single cancer center.

MATERIALS AND METHODS

The electronic medical records of enrolled patients with solid cancer were retrospectively reviewed. We evaluated factors associated with 6-month smoking cessation.

RESULTS

A total of 458 patients with cancer were included in this study. Their mean age was 62.9±10.3 years, and 56.3% of the participants had lung cancer. 193 (42.1%) had not yet begun their main treatment. The mean number of counseling sessions for the participants was 8.4±3.5, and 46 (10.0%) patients were prescribed smoking cessation medications. The 6-month smoking cessation success rate was 48.0%. Multivariate analysis showed that younger age (<65 years), cohabited status, early stage, and the number of counseling sessions were statistically significant factors affecting 6-month smoking cessation success (p<0.05). Initiation of a cessation program before cancer treatment was significantly associated with cessation success (odds ratio, 1.66; 95% confidence interval, 1.02-2.70; p=0.040).

CONCLUSION

Smoking cessation intervention must be considered when establishing a treatment plan immediately after a cancer diagnosis among smokers.

Cancer care clinicians' provision of smoking cessation support: A mixed methods study in New South Wales, Australia

OBJECTIVES

Given the importance of supporting cancer patients to quit smoking, we sought to ascertain cancer care clinicians' beliefs and practices regarding providing smoking cessation brief interventions.

METHODS

We used a cross-sectional sequential explanatory mixed method design, including a survey of multidisciplinary cancer care clinicians and semistructured interviews.

RESULTS

One hundred and sixty-five cancer care clinicians completed the survey and 21 participated in interviews. Over half of survey respondents (53%) said they do not regularly undertake smoking cessation brief interventions and 40% rarely or never advise quitting. Nonmetropolitan clinicians were more likely to discuss medication options and refer to the Quitline. Physicians were more likely to do brief interventions with patients and radiation therapists were least likely. Barriers were lack of training and experience, lack of knowledge of the Quitline referral process, lack of role clarity, lack of resources and systems, and perceived psychological ramifications of cancer for patients.

CONCLUSION

There is a need to upskill cancer clinicians and improve systems to provide smoking cessation brief interventions as part of routine clinical practice. All cancer care clinicians should complete brief intervention smoking cessation training relevant to the cancer context, including making referrals to Quitline, and be supported by systems to record and follow-up care.

Associations between cancer diagnosis and patients' responses to an inpatient tobacco treatment intervention

BACKGROUND

Diagnosis of a chronic illness, such as cancer may influence health behavior changes, such as smoking cessation. The present analyses examine associations between a cancer diagnosis (i.e., yes or no) and response to an opt-out smoking cessation bedside intervention provided to hospitalized patients. It was hypothesized that patients with a past or present cancer diagnosis would report higher motivation and engagement with quitting smoking, and higher rates of smoking abstinence after hospital discharge, compared to those without a cancer diagnosis.

METHODS

Chart review was conducted on 5287 inpatients who accepted bedside treatment from a counselor and opted-in to automated follow-up calls from July 2014 to December 2019.

RESULTS

At the time of inpatient assessment, those with a past or present cancer diagnosis (n = 419, 7.9%) endorsed significantly higher levels of importance of quitting than those without a cancer diagnosis (3.92/5 vs. 3.77/5), and were more likely to receive smoking cessation medication upon discharge (17.9% vs. 13.3%). Follow-up data from 30-days post-discharge showed those with a cancer diagnosis endorsed higher rates of self-reported abstinence (20.5%) than those without a cancer diagnosis (10.3%; p < 0.001).

CONCLUSION

Being hospitalized for any reason provides an opportunity for smokers to consider quitting. Having a previous diagnosis of cancer appears to increase intention to quit and lead to higher rates of smoking cessation in patients who are hospitalized compared to patients without cancer. Future research needs to work toward optimizing motivation for smoking cessation while admitted to a hospital and on improving quit rates for all admitted patients, regardless of diagnosis.

Prevalence and determinants of quitting smoking after cancer diagnosis: a prospective cohort study

OBJECTIVE

To describe smoking behaviours of patients with incident cancer attending an Italian cancer centre and to examine changes in their smoking habits within 12 months from cancer diagnosis, evaluating determinants of smoking cessation.

METHODS

A hospital-based prospective cohort included patients hospitalized in an Italian cancer centre (2016-2018). Patients were mostly female (74%) and included a limited proportion of aerodigestive cancers (7%). Face-to-face interviews were performed during hospital stay to gather information on patient characteristics and smoking history. Changes in smoking habits were assessed through telephone interviews at 3, at 6, and at 12 months after cancer diagnosis.

RESULTS

Among 1011 enrolled patients, 222 (22%) were current smokers at cancer diagnosis. Smoking prevalence was high in male patients (30%), in patients <50 years old (28%), in those with aerodigestive cancers (50%), and in those diagnosed at advanced stages (26%). Among current smokers at cancer diagnosis, 38% quit smoking after 12 months, 26% reduced intensity, and 36% did not modify smoking habits. Smoking cessation was associated with chemotherapy and, although not statistically significant, with female sex, older age, and advanced cancer stage. Patients with gastrointestinal, breast, or genitourinary cancer and those treated with surgery were less likely to quit smoking.

CONCLUSIONS

Our results highlighted that 62% of smoking patients with cancer did not quit the habit. Smoking cessation programs targeted to patients with cancer need intensification, particularly for those who may underestimate smoking effects after diagnosis.

The characteristics of patients who quit smoking in the year following a cancer diagnosis

PURPOSE

Continued tobacco smoking following a cancer diagnosis is associated with adverse outcomes. Our study aims to identify the demographic and clinical characteristics of survivors who quit smoking within a year of diagnosis.

METHODS

We conducted a secondary analysis of the Measuring Your Health (MY-Health) study, a community-based survey cohort of 5506 cancer patients registered across four Surveillance, Epidemiology, and End Results (SEER) cancer registries. Using surveys completed 6-13 months after diagnosis, we identified 868 participants who reported smoking around the time of cancer diagnosis and compared their current smoking status. We employed logistic regression models to predict current smoking status, adjusting for clinical and demographic variables.

RESULTS

The overall smoking cessation rate was 35% (n = 306). Survivors with non-small cell lung cancer were three times more likely to quit smoking compared to patients with non-smoking-related cancers (aOR = 3.23, 95% CI = 2.20-4.74). Participants with advanced stage cancer reported higher odds of quitting compared to those with localized cancer (aOR = 1.42, 95% CI = 1.02-1.96). Other characteristics that predicted quitting included being married, higher education level, and female sex (aOR = 2.01, 95% CI = 1.46-2.77; aOR = 1.74, 95% CI = 1.27-2.39; aOR = 1.54, 95% CI = 1.11-2.13, respectively).

CONCLUSIONS

This is one of the first studies to examine smoking cessation trends in a community-based, US cancer cohort during the year after diagnosis. Survivors with lung cancer and advanced cancer were significantly more likely to quit smoking.

IMPLICATIONS FOR CANCER SURVIVORS

Practitioners may use this knowledge to target interventions and address substantial disparities in cessation rates among survivors with early stage and non-lung cancers.

A systematic review of substance use and substance use disorders in patients with cancer

OBJECTIVE

Few studies examined substance use in cancer patients. The aims of this systematic review were to summarize this evidence, identify methodological limitations, and provide future research directions.

METHOD

Articles on substance use in cancer (focused on illicit substance, opioid, and alcohol use) were searched in Medline, PsycINFO, and PsycARTICLES.

RESULTS

On the basis of inclusion criteria, 28 studies were reviewed. Twenty-one contained empiric data from 500,123 participants; seven were review or conceptual papers. All studies were published between 1995 and 2018. Quality assessment revealed relatively low risk of bias and high methodological quality. Five studies examined substance use or substance use disorder (SUD) broadly. Mean ages ranged from 17.6 to 74.7 years. Substance use rates ranged from 2% to 35%, with a median opioid rate of 18% and 25.5% for alcohol. Nine of the studies had samples comprised either mostly or exclusively of advanced cancer patients. Disease groups included breast, head & neck, and gastric cancer. None of the studies used a theoretical framework or model.

CONCLUSIONS

Given the prevalence of substance use in cancer patients, interventions are needed. Further theory-grounded studies are warranted to foster the translation of research into clinical practice and elucidate substance use management recommendations.

Continued smoking after a cancer diagnosis: a longitudinal study of intentions and attempts to quit

PURPOSE

Continued smoking after a cancer diagnosis is associated with poor treatment outcomes and reduced life expectancy. We aimed to identify the stability of smoking status after diagnosis including quit attempts and quit intentions.

METHODS

Participants with a first primary cancer diagnosis were recruited via two state-based registries in Australia. Questionnaires were mailed at approximately 6 months (T1), 1 year (T2), 2 years (T3), and 3.5 years (T4) post-diagnosis. Smoking status and quitting intentions were assessed at each time point.

RESULTS

A cohort of 1444 people was recruited. People who indicated that they were more than 9 months post-diagnosis are excluded from analysis, leaving 1407 eligible study participants. Sixty-six (37%) of the 178 self-reported smokers at diagnosis had quit in the 6-month post-diagnosis (T1), the remaining 112 (63%) reported being a current smoker. Of the smokers at T1, 40% intended to quit: with 8% having quit smoking by T2; 11% quit by T3; 12% quit by T4. Of those who reported at T1 that they intended to quit in the next 6 months, 10% or fewer reported having quit at any subsequent time point. Quitting attempts decreased in frequency over time post-diagnosis. Less than 15% of respondents who had quit at or shortly before diagnosis reported relapse to smoking at each time point.

CONCLUSIONS

The majority of smokers diagnosed with cancer continue to smoke beyond diagnosis, even in the context of an intention to quit and attempts to do so. Cancer survivors who smoke remain motivated to quit well beyond the initial diagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

There are clear positive clinical effects of smoking cessation for those who have undergone treatment for cancer, both for short-term treatment outcomes, and for long-term survivorship. Given the substantial rates of continued smoking among those who report smoking at diagnosis and their continued attempts to quit during survivorship, there is a need for improved cessation support initiatives for people diagnosed with cancer. These initiatives need to continue to be offered to smokers long after the initial diagnosis and treatment.

Prevalence and Predictors of Sustained Smoking after a Cancer Diagnosis in Korean Men

Purpose

Although smoking has a significant impact on mortality and morbidity of cancer patients, many patients continue to smoke post-diagnosis. The purpose of this study was to investigate prevalence and predictors of sustained smoking among male cancer survivors.

Materials and Methods

The Korean National Health Insurance Service-National Health Screening Cohort database was used for this population-based, retrospective study. Study subjects were 15,141 men who were diagnosed with their first incident cancer between 2004 and 2011. Changes in smoking status before and after a cancer diagnosis were investigated. For patients who were current smokers pre-diagnosis, association between post-diagnosis sustained smoking and demographic, socioeconomic, and clinical variables were examined.

Results

Of the 4,657 pre-diagnosis smokers, 2,255 (48%) had quit after cancer diagnosis, while 2,402 (51.6%) continued to smoke. In a multivariate logistic regression analysis, younger age at cancer diagnosis (adjusted odds ratio [aOR], 1.37; 95% confidence interval [CI], 1.21 to 1.55; p < 0.001), low socioeconomic status (aOR, 1.29; 95% CI, 1.15 to 1.45; p ≤ 0.001), pre-diagnosis heavy smoking (aOR, 1.24; 95% CI, 1.09 to 1.41; p=0.001), diagnosis of non-smoking–related cancer (aOR, 1.67; 95% CI, 1.42 to 1.96; p < 0.001), and high serum glucose level (aOR, 1.23; 95% CI, 1.03 to 1.46; p=0.019) were associated with sustained smoking after a cancer diagnosis.

Conclusion

Almost half of the male smokers continue to smoke after a cancer diagnosis. Targeted interventions for smoking cessation should be considered for patients with younger age, low socioeconomic status, heavy smoking history, non-smoking–related cancer, and high blood glucose levels.

Associations between the smoking-relatedness of a cancer type, cessation attitudes and beliefs, and future abstinence among recent quitters

OBJECTIVE

Smoking after a diagnosis of cancer can negatively impact treatment outcomes and quality of life. It is important that patients quit smoking and remain abstinent regardless of cancer type. Some cancer types (eg, lung) have stronger links to smoking as a cause than do others (eg, colorectal). The aims of this study were to (1) assess associations between smoking-relatedness of the cancer type with beliefs and attitudes concerning smoking abstinence (eg, confidence, self-efficacy), and (2) assess these variables as predictors of future abstinence.

METHODS

In this secondary analysis, cancer patients (N = 357) who quit smoking within the previous 90 days were assigned a code of 3, 2, or 1 according to the cancer type's level of smoking-relatedness: Very related (n = 134, thoracic and head and neck), Somewhat related (n = 93, acute myeloid leukemia, bladder, cervix, colorectal, esophageal, kidney, liver, pancreas, and stomach), and Unlikely related (n = 137, all other cancer types).

RESULTS

Smoking-relatedness was positively associated with plan to stay smoke-free, maximum confidence in being smoke-free in 6 months, higher abstinence self-efficacy, and lower expected difficulty in staying smoke-free. Each of the 4 beliefs and attitude variables predicted abstinence 2 months later. Smoking-relatedness also predicted abstinence in a univariate model, but not in a multivariable model with the belief and attitude variables. Using backwards stepwise procedures, the final model included plan to stay smoke-free, confidence in being smoke-free, and abstinence self-efficacy.

CONCLUSION

These results are consistent with our conceptualization of cessation motivation differing by smoking-relatedness of the cancer type and predicting future abstinence.

Oncologist provision of smoking cessation support: A national survey of Australian medical and radiation oncologists

AIM

Continued smoking in patients diagnosed with cancer affects treatment outcomes and overall survival. With national surveys of Australian medical oncologists (MO) and radiation oncologists (RO) we sought to determine current clinical practices, preferences and barriers in providing patient smoking cessation support.

METHODS

Oncologist members of the Medical Oncology Group of Australia (n = 452) and Trans-Tasman Radiation Oncology Group (n = 230) were invited to participate in a multiple choice survey exploring smoking cessation practices and beliefs.

RESULTS

The survey response rate was 43%. At first consultations more than 90% of MO and RO regularly asked patients if they smoke or use tobacco products, closely followed by documentation of duration of smoking history and current level of consumption. Less common was asking the patient if they intended to quit (MO 63%, RO 53%) and advising cessation (MO 70%, RO 72%). Less than 50% of oncologists regularly asked about current smoking in follow-up consultations. Although a range of referral options for smoking cessation care were used by oncologists, only 2% of MO and 3% of RO actively managed the patients' smoking cessation themselves and this was the least preferred option. The majority believed they require more training in cessation interventions (67% MO, 57% RO) and cited multiple additional barriers to providing cessation care.

CONCLUSIONS

Oncologists strongly prefer smoking cessation interventions to be managed by other health workers. A collaborative approach with other health professionals is needed to aid the provision of comprehensive smoking cessation care tailored to patients with cancer.

Internet-based self-help smoking cessation and alcohol moderation interventions for cancer survivors: a study protocol of two RCTs

Background

Brief interventions for smoking cessation and alcohol moderation may contribute considerably to the prevention of cancer among populations at risk, such as cancer survivors, in addition to improving their general wellbeing. There is accumulating evidence for the effectiveness of internet-based brief health behaviour interventions. The objective of this study is to assess the effectiveness, patient-level cost-effectiveness and cost-utility of two new online theory-based self-help interventions among adult cancer survivors in the Netherlands. One of the interventions focuses on alcohol moderation, the other on smoking cessation. Both interventions are tailored to cancer survivors.

Methods

Effectiveness will be assessed in two separate, nearly identical 2-armed RCTs: alcohol moderation (AM RCT) and smoking cessation (SC RCT). Participants are randomly allocated to either the intervention groups or the control groups. In the intervention groups, participants have access to one of the newly developed interventions. In the control groups, participants receive an online static information brochure on alcohol (AM RCT) or smoking (SC RCT). Main study outcome parameters are the number of drinks post-randomisation (AM RCT) and tobacco abstinence (SC RCT). In addition, cost-data and possible effect moderators and mediators will be assessed. Both treatments are internet-based minimally guided self-help interventions: MyCourse – Moderate Drinking (in Dutch: MijnKoers – Minderen met Drinken) and MyCourse – Quit Smoking (MijnKoers – Stoppen met Roken). They are based on cognitive behaviour therapy (CBT), motivational interviewing (MI) and acceptance and commitment therapy (ACT). Both interventions are optimized in collaboration with the target population of cancer survivors in focus groups and interviews, and in collaboration with several experts on eHealth, smoking cessation, alcohol misuse and cancer survivorship.

Discussion

The present study will add to scientific knowledge on the (cost-)effectiveness of internet-based self-help interventions to aid in smoking cessation or alcohol moderation, working mechanisms and impact on quality of life of cancer survivors. If found effective, these interventions can contribute to providing evidence-based psychosocial oncology care to a growing population of cancer survivors.

Trial registration

Trials are prospectively registered in The Netherlands Trial Register (NTR): NTR6011 (SC RCT), NTR6010 (AM RCT) on 1 September 2016.

Barriers and facilitators to smoking cessation in a cancer context: A qualitative study of patient, family and professional views

Background

Continued smoking after cancer adversely affects quality of life and survival, but one fifth of cancer survivors still smoke. Despite its demands, cancer presents an opportunity for positive behaviour change. Smoking often occurs in social groups, therefore interventions which target families and individuals may be more successful. This qualitative study explored patients, family members and health professionals’ views and experiences of smoking and smoking cessation after cancer, in order to inform future interventions.

Methods

In-depth qualitative interviews (n = 67) with 29 patients, 14 family members and 24 health professionals. Data were analysed using the ‘Framework’ method.

Results

Few patients and family members had used National Health Service (NHS) smoking cessation services and more than half still smoked. Most recalled little ‘smoking-related’ discussion with clinicians but were receptive to talking openly. Clinicians revealed several barriers to discussion. Participants’ continued smoking was explained by the stress of diagnosis; desire to maintain personal control; and lack of connection between smoking, cancer and health.

Conclusions

A range of barriers to smoking cessation exist for patients and family members. These are insufficiently assessed and considered by clinicians. Interventions must be more effectively integrated into routine practice.

Smoking at diagnosis significantly decreases 5-year cancer-specific survival in a population-based cohort of 18 166 colon cancer patients

BACKGROUND

Accumulating evidence suggests smoking may adversely affect cancer patients' outcomes. Previous studies of smoking and survival in colon cancer have been limited by size and/or lack of a population basis and results have been inconsistent.

AIM

To investigate in a large population-based cohort whether smoking status at diagnosis is an independent prognostic factor for cancer-specific survival in colon cancer and whether treatment modifies any impact of smoking.

METHODS

Colon adenocarcinomas diagnosed between 1994 and 2012 were abstracted from the National Cancer Registry Ireland, and classified by smoking status at diagnosis. Cancer-specific death rates over 5 years were compared in current, ex- and never smokers using multivariable Cox proportional hazards models, and subgroup analyses by treatment (combinations of cancer-directed surgery and chemotherapy) were conducted.

RESULTS

Of 18 166 colon cancers, 20% of patients were current smokers, 23% ex-smokers and 57% never smokers. Compared to never smokers, current smokers had a significantly raised cancer death rate [multivariable hazard ratio (HR) = 1.14, 95% CI: 1.07-1.12]. There was a significant interaction between treatment and smoking (P = 0.03). In those who had cancer-directed surgery only, but not other groups, current smokers had a significantly increased cancer death rate compared to never smokers (HR = 1.21, 95% CI: 1.09-1.34).

CONCLUSIONS

Smoking at diagnosis is an independent prognostic factor for colon cancer. The limitation of the association to surgically-treated patients suggests that the underlying mechanism(s) may be related to surgery. While further research is needed to elucidate mechanisms, continued efforts to encourage smoking prevention and cessation may yield benefits in terms of improved survival from colon cancer.

Treating Nicotine Dependence and Preventing Smoking Relapse in Cancer Patients

INTRODUCTION

Despite the well-documented harmful effects of smoking, many cancer patients continue to smoke. Smoking cessation is critical to address in this population given the associated increase in treatment toxicity, risk of second primary tumors, decrease in treatment response and higher disease-specific and all-cause mortality with continued smoking following a cancer diagnosis. This review seeks to summarize the latest recommendations and guidelines on smoking cessation treatment for patients diagnosed with cancer, and the evidence behind those recommendations.

AREAS COVERED

We reviewed the latest evidence for smoking cessation treatments for cancer patients and the clinical guidelines and recommendation available for oncologists and health care providers. The unique aspects of nicotine dependence among patients diagnosed with cancer, and key challenges and barriers that cancer survivors and health care providers experience when considering smoking cessation treatments, and available clinical resources, are also discussed. Lastly, the authors summarize future directions in the field of smoking cessation treatment for cancer patients.

EXPERT COMMENTARY

While there are areas of improvement in research of smoking cessation treatment for cancer patients, critical under-explored areas remain. Nonetheless, providers should adhere to the NCCN guidelines and offer a brief counseling intervention to motivate patients to quit smoking when appropriate resources are not available.

Integrating tobacco treatment into cancer care: Study protocol for a randomized controlled comparative effectiveness trial

BACKGROUND

Despite the well-established risks of persistent smoking, 10-30% of cancer patients continue to smoke after diagnosis. Evidence-based tobacco treatment has yet to be integrated into routine oncology care. This paper describes the protocol, manualized treatment, evaluation plan, and overall study design of comparing the effectiveness and cost of two treatments across two major cancer centers.

METHODS/DESIGN

A two-arm, two-site randomized controlled comparative effectiveness trial is testing the hypothesis that an Intensive Treatment (IT) intervention is more effective than a Standard Treatment (ST) intervention in helping recently diagnosed cancer patients quit smoking. Both interventions include 4 weekly counseling sessions and FDA-approved smoking cessation medication advice. The IT includes an additional 4 biweekly and 3 monthly booster sessions as well as dispensal of the recommended FDA-approved smoking cessation medication at no cost. The trial is enrolling patients with suspected or newly diagnosed cancer who have smoked a cigarette in the past 30days. Participants are randomly assigned to receive the ST or IT condition. Tobacco cessation outcomes are assessed at 3 and 6months. The primary study outcome is 7-day point prevalence biochemically-validated tobacco abstinence. Secondary study outcomes include the incremental cost-effectiveness of the IT vs. ST.

DISCUSSION

This trial will answer key questions about delivering tobacco treatment interventions to newly diagnosed cancer patients. If found to be efficacious and cost-effective, this treatment will serve as a model to be integrated into oncology care settings nation-wide, as we strive to improve treatment outcomes and quality of life for cancer patients.