Anytime that you are working with individuals who are quitting smoking, it is important to assess for depression and consider treatments for depression.
—Vani Nath Simmons, PhD
In the News focuses on media reports that your patients may have questions about at their next visit. This continuing column will provide summaries of articles in the popular press that may prompt such questions, as well as comments from colleagues in the field.
Patients with head and neck or lung cancer who quit smoking even the week before surgical treatment are much more likely to remain abstinent from smoking and to reap the benefits of continued abstinence from smoking than are those who wait until after surgery to quit. These benefits—as listed in a study published in the journal Cancer,1 and as reported by health and consumer media—can be immediate, such as increased efficacy of treatment and reduced rates of surgical complications and adverse effects, and long-term, such as reduced risk of cancer recurrence, second primary tumors, heart disease, and other smoking-related illnesses.
“Patients with cancer need to know that it is never too late to quit smoking,”noted Vani Nath Simmons, PhD, the study’s corresponding author and Assistant Member in the Health Outcomes and Behavior Department at the H. Lee Moffitt Cancer Center, and Assistant Professor at the University of South Florida in Tampa, Florida. “Regardless of the cancer type or stage, benefits can certainly be seen by quitting smoking and staying quit after cancer treatment,” she said in an interview with The ASCO Post.
“Research shows that the outcomes for just about any cancer and any treatment, and the quality of life, regardless of the duration of the life remaining, are higher if patients do in fact quit smoking,” Thomas H. Brandon, PhD, added. A coauthor of the study, Dr. Brandon is Chair of the Health Outcomes and Behavior Department and Director of the Tobacco Research and Intervention Program at Moffitt Cancer Center.
Relapse Rates Vary Significantly
A total of 154 patients, recruited from the thoracic and head and neck clinics at Moffitt Cancer Center, participated in the study. All had a history of smoking at least 10 cigarettes per day for at least 1 year before a diagnosis of cancer. All patients were abstinent from smoking for at least 24 hours after surgery; 53 patients had quit smoking shortly before surgical cancer treatment, and 101 had quit smoking immediately after surgery.
Smoking behavior was assessed at 2, 4, 6, and 12 months after surgery. While all patients had access to Moffitt’s certified tobacco cessation specialist, no smoking intervention was provided as part of the study.
“Relapse rates varied significantly, depending on presurgery smoking status. At 12 months after surgery, 60% of patients who smoked during the week prior to surgery had resumed smoking vs only 13% of patients who were abstinent prior to surgery. Notably, these relapse rates are lower than among smokers in the general population (95%), likely reflecting the high level of motivation and interest in smoking cessation expressed by patients with cancer,” according to the study report.
Predictors of Smoking Relapse
The study found several variables (measured at baseline) that were predictors of smoking relapse. Among patients who quit smoking before surgery, the two significant factors predicting relapse were higher perceived difficulty quitting and lower perceived links between smoking and cancer. Among patients still smoking before surgery, significant predictors of relapse were “higher depression proneness,” greater fears about cancer recurrence, and lower expectations about being able to quit (self-efficacy for quitting).
“Anytime that you are working with individuals who are quitting smoking, it is important to assess for depression and consider treatments for depression,” Dr. Simmons said.
Dr. Brandon added, “Depression and smoking are often comorbid. Smokers are twice as likely as nonsmokers to have a history of depression and vice versa. Some of these people have been treated for depression or need formal treatments for depression, while some just need to learn other skills to replace smoking as their main mood control mechanism.”
For smokers trying to quit, nicotine withdrawal can cause more depressed moods. Those moods generally improve in about 2 to 3 weeks, although that varies by individual, Dr. Brandon noted. “In the long run, people are generally less depressed after they quit smoking,” he said.
Greater fear of cancer recurrence “was an interesting variable for us to measure because we didn’t know how it was going to play out,” Dr. Simmons said. “If somebody has a fear of their cancer recurring, might that protect them in terms of making them less likely to smoke, or might it cause more anxiety or depression, which we know is strongly related to smoking? And that second possibility is actually the way that the results came out.”
Interventions for these people should directly address their fear, negative mood, and relationship to smoking. “We talk to them about alternative ways (other than smoking) to deal with negative mood and fears or anxieties they have about their cancer,” Dr. Simmons explained.
“The construct of self-efficacy in smoking is one that has been well studied, even outside of the cancer population,” Dr. Simmons noted. “We know that individuals with lower self-efficacy or confidence in their quitting are more likely to resume smoking,” she explained. The results reported in the current study “support the need for relapse prevention interventions that address quitting self-efficacy,” the investigators wrote. “Testimonials from cancer patients who have long histories of smoking and have successfully maintained their abstinence after cancer treatment may prove effective.”
Relapse Prevention Trial
“Based on the results of this study, we are now running a clinical trial that is testing a smoking relapse intervention and in fact uses patient testimonials as one way to enhance self-efficacy,” Dr. Simmons said. These testimonials are included on a DVD that patients in the intervention arm of the trial receive while they are still in the hospital, along with a self-help booklet. Then over the course of the first 3 months after they’ve left the hospital, patients receive the remaining seven booklets in the series. Patients randomized to the usual care arm would have access to the smoking cessation and relapse prevention services offered to all patients at Moffitt identified as smokers.
“Because this was a longitudinal study, we were able to look at the trajectories of relapse over time and found that the high-risk period where most of the relapse occurred was in the first 2 months,” Dr. Simmons said. “This would really suggest, consistent with literature already published, that some sort of contact or intervention needs to occur even after individuals leave the hospital setting. Certainly once symptoms start to dissipate and patients start to feel better, their risk of relapse may increase,” she noted.
“When you get a cancer diagnosis, it is a shocking experience and you may have these great intentions to quit smoking and may even be able to quit smoking for a while,” Dr. Brandon said. “What we know less about are the long-term outcomes of these attempts, once patients habituate to the idea that they have cancer, and especially if they are being successfully treated—do they maintain that same motivation to quit smoking?”
He continued, “It reminds me of another area of our research, which is smoking cessation in pregnant women. Many pregnant women will quit smoking when they become pregnant—not enough, but more than in the general population. They are very motivated at that point, but almost all of them relapse after they deliver the baby, despite the risk of secondhand smoke to the baby. There is a short-term motivation, but that may not persist for the long term.”
The self-help booklets are from the Forever Free series developed under the leadership of Dr. Brandon and “shown to be effective in two clinical trials, as well as very cost-effective,” Dr. Simmons said. “Our thinking behind the intervention was to take something that has already been demonstrated to be effective in reducing relapse among the general population and combine that with more targeted information specifically for cancer patients, which we have done through the DVD format.” The Forever Free booklets are posted on the National Cancer Institute website at www.smokefree.gov.
“This is a relatively inexpensive and highly disseminable type of intervention,” Dr. Brandon noted. “If it is validated in the clinical trial, it is something that could be used by cancer centers or other hospitals around the country.” ■
Disclosure: Drs. Simmons and Brandon reported no potential conflicts of interest.
1. Simmons VN, Litvin EB, Jacobsen PB, et al: Predictors of smoking relapse in patients with thoracic cancer or head and neck cancer. Cancer. December 20, 2012 (early release online).
“Receiving a cancer diagnosis represents a ‘teachable moment’ for delivering smoking cessation and relapse prevention interventions,” concluded a study in the journal Cancer1 about smoking relapse in patients with thoracic cancer or head and neck cancer. Previous research by two of the study’s...