Correlates of tobacco use among smokers and recent quitters diagnosed with cancer

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Abstract

Smoking after a cancer diagnosis shortens survival time, increases risk of recurrence and the development of another primary tumor, reduces treatment efficacy, and increases treatment complications. Nevertheless, many patients who smoked prior to their illness continue to smoke after diagnosis and treatment. The development of effective smoking cessation interventions for cancer patients has been slowed by the lack of data concerning psychological correlates of smoking in this population. This study, with 74 cancer patients, showed that smoking and lower readiness to quit was associated with: having relatives at home who smoke, a longer time between diagnosis and assessment, completion of medical treatment, greater nicotine dependence, lower self-efficacy, quitting pros, and risk perceptions, and higher quitting cons, fatalistic beliefs, and emotional distress. Thus, smoking cessation treatments for cancer patients should include pharmacotherapy, relapse prevention, and counseling designed to facilitate self-efficacy, quitting pros, and risk awareness and to reduce the quitting cons, fatalism, and distress.

Introduction

Continued smoking among cancer patients is a serious health problem [1], [2], [3]. Compared to head and neck and lung cancer patients who quit smoking upon learning of their diagnosis, patients who continue to smoke exhibit: reduced survival time [4], [5], [6], [7], [8], [9], greater risk of disease recurrence, and higher risk for a second primary tumor [10], [11], [12], [13], [14], [15]. Continued smoking among cancer patients also leads to an increased rate and duration of symptoms that can reduce patients’ physical well-being and quality of life (e.g. mucositis, impaired pulmonary function, loss of taste, dry mouth, impaired wound healing, tissue and bone necrosis, and difficulty regaining the quality of their voice) [16], [17], [18], [19], [20], [21], [22]. Further, the effectiveness of radiotherapy is diminished by continued smoking [1], [4]. Despite the health advantage of quitting smoking after a diagnosis of cancer, 23–35% of head and neck cancer patients [9], [23], [24], [25], [26] and 13–20% of lung cancer patients [7], [27], [28], [29], [30], [31] who smoked before their diagnosis continue to do so after diagnosis and treatment.

These data support the need for smoking cessation treatments as part of usual medical care for cancer patients [2], [3], [24], [27]. Prior studies show that worry about one’s health is the primary reason cited for quitting smoking [32], [33] and that medical crises heighten concern with smoking cessation and increase the likelihood of self-initiated quitting [34], [35], [36], [37]. Thus, smoking cessation treatments for cancer patients may be effective since an intervention can exploit the heightened motivation to quit and openness to cessation messages that are common among hospitalized patients, especially those receiving care for a smoking-related illness, such as cardiovascular disease [37], [38]. The development of smoking cessation treatments for cancer patients can be guided by an understanding of the factors that distinguish between patients who quit smoking after their diagnosis and patients who continue to smoke: (1) identifying demographic and medical correlates of continued smoking could permit targeted treatments for high-risk patients; (2) delineating the psychological correlates of continued smoking could help guide the design of the behavioral counseling component to cessation treatments; and (3) detecting dependence correlates of continued smoking would suggest the need for the inclusion of pharmacotherapies in smoking cessation programs.

Cancer patients remain a population that has not been heavily targeted by tobacco control researchers and clinicians with regard to the assessment of correlates of smoking behavior [27], [33], [39], [40]. The studies which have examined correlates of smoking behavior among cancer patients have almost exclusively focused on medical [23], [24], [25], [26], [41], demographic [23], [24], [25], [26], [41], and nicotine dependence [23], [25], [41] variables, and few consistent findings have been reported. In addition, the majority of studies have been conducted with head and neck cancer patients, with a few having utilized samples of lung cancer patients. In one study that examined psychological correlates of smoking behavior among cancer patients, Gritz et al. [23] assessed baseline differences between head and neck cancer patients who were classified as relapsers or continuous abstainers at a 12-month follow-up assessment. While the two groups were no different in terms of coping behaviors used to resist smoking or the use of social support, abstainers exhibited significantly higher levels of quitting self-efficacy (i.e. confidence in ability to quit smoking) as well as readiness to quit (i.e. stage-based measure of intentions to quit), compared to relapsers (see also [41]). These findings are compatible with theoretical models of smoking behavior, i.e. the transtheoretical (TTM; [42]) and cognitive-social health information-processing (C-SHIP; [43]) models and conform to results produced from research with the general population [44], [45] and with cardiac patients [5], [46], [47].

However, these models identify additional psychological determinants of smoking behavior as well, including: risk perceptions (i.e. awareness of the adverse health effects of smoking), health beliefs (i.e. fatalistic attitudes, the pros and cons of quitting), and emotional distress. Data accumulated from research with the general population suggest that continued smoking among cancer patients may be a function of the tendency of persistent smokers to: minimize their own vulnerability to smoking-related illnesses (e.g. recurrence) [48], [49], focus on the cons of quitting (e.g. smoking relieves tension) rather than the pros (e.g. quitting will improve their health) [50], [51], [52], [53], maintain fatalistic health beliefs (e.g. no use in quitting, since cancer is fatal) [54], [55], [56], [57], [58], and experience emotional distress about quitting [59], [60], [61], [62].

To date, the degree to which these psychological processes influence smoking behavior among cancer patients remains an essentially unexplored area of research. While we acknowledge that a range of factors can influence the smoking behavior of cancer patients—including provider and system factors, such as access to nicotine addiction treatments—providing a better understanding of the role of psychological processes in determining smoking behavior can help guide the design of clinical treatments for this population. Based on data from the general population of smokers, this study tested the hypothesis that compared to abstainers and those at higher stages of readiness to quit, smokers and patients exhibiting a lower stage of readiness to quit would report: lower levels of self-efficacy, pros of quitting, and risk perceptions (e.g. risk of recurrence), as well as higher levels of cons of quitting, fatalistic health beliefs, and emotional distress. We also examined medical, demographic, and addiction correlates of smoking.

Section snippets

Participants

Study participants were 74 cancer patients recruited from a large, nationally recognized comprehensive cancer center over the course of 12 months. Eligibility criteria included: a diagnosis of head or neck or lung cancer (confirmed by the medical chart), self-reported current or former smoker (i.e. quit within the last 6 months), ability to communicate in English, and self-reported absence of drug (other than tobacco) or alcohol abuse. We excluded patients who had quit for longer than 6 months

Rate of smoking and readiness to quit

Using 7-day point prevalence to assess smoking status, 29 patients (39%) were classified as smokers, whereas 45 patients (61%) were categorized as abstainers. Of the 29 patients classified as smokers, 18 of them (62%) reported that they had not attempted to quit for 24 h in the previous 6 months, whereas 11 (38%) reported a 24 h quit attempt, but were currently smoking. With regard to readiness to quit, 4 patients (5.4%) were classified as contemplators, 25 patients (34%) were in the preparation

Discussion

The present study assessed demographic, medical, dependence, and psychological correlates of smoking status and readiness to quit among head and neck and lung cancer patients. While most demographic variables were unrelated to smoking behavior, certain medical variables, nicotine dependence, and the proposed psychological processes differentiated between patients who continued to smoke following their diagnosis and those who quit. Although this study offers important information for guiding the

Conclusions and practice implications

Overall, this study provides some of the first evidence that psychological variables previously associated with smoking behavior in non-cancer populations are also linked with the smoking behavior of cancer patients. In turn, since nearly all of the research with the C-SHIP and the TTM models has been conducted with non-cancer groups, this study provides preliminary support for the generalizability of these frameworks to the context of tobacco use by cancer patients. Moreover, this study offers

Acknowledgements

Support for this study was provided by National Institutes of Health Grants CA57708, CA06927, CA88610, and CA76644. This study was reviewed and approved by the Fox Chase Cancer Center Institutional Review Board.

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