Jamie S Ostroff and Lara K Dhingra

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In the past two decades, cancer has shifted from an acute disease with certain fatality to a curable or chronic condition with increasing rates of long-term survival. Due to advances in early detection and treatment, nearly 64% of the U.S. adults diagnosed with cancer will survive beyond 5 years compared to only 33% of individuals diagnosed in I960.1 With more than 10 million cancer survivors in the United States2 and this number expected to double by 20503 there is a growing need to understand the unique medical, treatment, and psychosocial sequelae in this rapidly-changing population. Recognizing that cancer survivors are at increased risk for the development of second primary cancers, cancer recurrence, treatment late effects, and other chronic health conditions, there has been a call for multidisciplinary cancer care approaches to address behavioral risk factors that could reduce morbidity and mortality in cancer survivors.4 However, despite this emphasis on the development of interventions to improve the post-diagnosis health of cancer survivors, tobacco use in cancer survivors is largely an underappreciated area for health behavior change.

While it is well-known that tobacco use is the leading cause of cancer mortality in the United States annually (30% or 80,000 of all cancer deaths),5 continued smoking following cancer diagnosis also has adverse health outcomes. Specifically, cancer survivors who smoke have a higher risk of morbidity and mortality, treatment-related complications,6-11 higher risk of recurrence and second primary disease,7,12-19 and poorer quality of life.20 In addition to well-established causal links to cancers of the lung and head and neck, smoking increases the risk of cancers of the pancreas, bladder, kidney, uterine cervix, stomach, and acute myeloid leukemia.21

Cancer survivorship provides extraordinary opportunities, as well as challenges to promoting smoking cessation.22 By personalizing the harms of smoking and focusing efforts on the restoration and maintenance of good health, cancer diagnosis can be a catalyst for smoking cessation among cancer survivors and their tobacco-dependent loved ones. However, cancer also invokes unique challenges to smoking behavior change that must be considered in the development and implementation of smoking cessation programs for cancer survivors.

In this chapter, we will: (1) provide a rationale for the importance of providing smoking cessation programs to cancer survivors and their families; (2) review prevalence rates of smoking and cessation; (3) briefly review clinical practice guidelines for the delivery of evidence-based, smoking cessation interventions in cancer care; (4) summarize the unique challenges of promoting smoking cessation in cancer survivors, and (5) highlight future directions for promoting smoking cessation in cancer survivorship.

Cancer survivorship is a relatively new phase in the continuum of cancer care. Established by the National Cancer Institute (NCI) in 1996, the Office of Cancer Survivorship has adopted the National Coalition of Cancer Survivors (NCCS) definition of a cancer survivor23 which specifies that "an individual is considered a cancer survivor from the time of diagnosis, through the balance of his or her life. Family members, friends and caregivers are also impacted by the survivorship experience and are therefore included in this definition." Providing useful guideposts for cancer survivorship, Fitzhugh Mullan24 outlined three seasons of survival each with unique sets of issues and concerns. Acute survival begins with the diagnosis of the cancer and is dominated by diagnostic and therapeutic efforts. Extended survival is a period during which a patient goes into remission or has terminated the active treatment and enters a phase of medical surveillance or "watchful waiting" with periodic examinations and tests. Psychologically, this phase of survival is often dominated by fear of recurrence and uncertainty. Patients may cope with physical symptoms such as fatigue and pain. Permanent survival is roughly equated with "cure"; however, medical late effects and psychosocial sequelae often persist as chronic reminders of cancer and its treatment. This review will focus predominantly on the extended and long-term phase of survivorship.

Because of the dearth of literature regarding other forms of tobacco use (e.g., cigars, pipes, smokeless tobacco), this chapter will focus on cigarette smoking. However, interested readers are referred to quality reviews on smokeless tobacco and other forms of tobacco.25-27


While the general health risks of smoking are well documented, perhaps less disseminated are the specific health risks of continued smoking in cancer survivors and specific benefits associated with smoking cessation. As presented below, there is a growing body of literature supporting the positive effects of quitting smoking following cancer diagnosis. Smoking cessation among cancer survivors has been associated with a decreased risk of new primary disease, cancer recurrence and/or treatment complications. Although much of the prior work has been conducted with tobacco-related cancers, there is also evidence that cessation is associated with specific health benefits across non-tobacco-related cancer types as well. Cancer care providers are encouraged to provide personalized quitting advice about the health benefits of cessation as outlined in the following section so as to enhance quitting motivation in cancer survivors.

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