Patient Related Barriers to Smoking Cessation

There are several patient level barriers for smoking cessation in cancer survivors including high nicotine dependency, urgency of cessation advice, cancer-specific health beliefs, psychological distress, disease and treatment variables, social network influences and misreporting of smoking status.

Table 3. Smoking Cessation in Cancer Survivors

Benefits

Improved survival rate Fewer treatment complications Improved treatment efficacy

Reduced risk of disease recurrence and

2nd primary tumor Improved mastery and control Reduced risk of smoking-related chronic conditions

Barriers

High psychological distress High nicotine dependence Abrupt cessation vs. "commitment to abstinence" Low quitting self-efficacy

Knowledge deficits Negative social support

Patients diagnosed with tobacco-related cancers typically report long histories of heavy tobacco use.62,68,86 Heavy cumulative tobacco exposure is associated with strong nicotine dependency and severe withdrawal symptoms (i.e., cravings, restlessness, difficulty concentrating, insomnia, etc.) following smoking abstinence. Thus, cessation approaches in cancer survivors may require consideration of combined pharmacotherapies to address both nicotine withdrawal and other common symptoms such as anxiety and depression.

The perceived urgency for abrupt and immediate cessation following cancer diagnosis may diminish the likelihood for long-term smoking abstinence. Smoking cessation programs often suggest the importance of behaviors such as preplanning a "quit date" and practicing techniques for coping with smoking urges. When cancer patients are hospitalized or otherwise immediately begin a course of active cancer treatment, this pre-quit planning phase may be necessarily disrupted. In addition, patients' pre-quit planning and problem-solving skills may be overwhelmed by psychological distress related to cancer diagnosis. We have found that smokers who are able to quit prior to hospital admission are more likely to maintain long-term smoking abstinence into extended survivorship. Thus, patients should be advised to give thoughtful consideration regarding how they can anticipate some of the quitting challenges, and elicit support.

Cancer patients may have a general lack of knowledge about the health benefits of smoking cessation specific to the course of their cancer. Indeed, tobacco-dependent cancer patients often report fatalistic health beliefs such as "the damage is done" and that "it is too late to quit." Compounded by an extensive history of heavy tobacco use, and the likelihood of prior failed attempts to quit smoking, self-doubting beliefs may foster low self-efficacy for quitting, a potent barrier to smoking cessation. Relatedly, cancer survivors' knowledge about specific health risks of smoking (e.g., impact on cancer recurrence or second primary cancer) may be potent motivators of smoking behavior change.88 Wold and colleagues88 examined causal attributions related to cancer diagnosis in cancer survivors and showed that most cancer survivors, regardless of smoking status, believed that smoking would cause the same type of cancer diagnosis in other people. However, only about 17% of former smokers and 30% of current smokers believed that smoking had caused their own cancer.88 To address these health belief barriers, health care providers should offer personalized advice about the short-term benefits of smoking cessation when addressing patients' concerns about cancer risk factors, medical late effects and preventing disease recurrence. Further, targeted strategies to enhance quitting self-efficacy for demoralized patients may be highly effective given that cancer patients with higher self-efficacy for quitting are more likely to achieve and maintain long-term cessation.84,89-94

Stressful life events and negative affect (i.e., depression; anxiety, and anger) are well-known barriers to smoking cessation and strong triggers for smoking relapse following attempts to quit.95 Heightened psychological distress has been reported along the entire continuum of cancer care in some survivors (e.g., ref. 96). Long-term and highly nicotine-dependent smokers may rely heavily on their smoking as a mood regulation strategy to decrease negative affect and increase positive affect. 95 Cancer survivors with high levels of negative affect or in particular, those survivors with comorbid anxiety, posttraumatic stress or depressive symptoms may be at acute risk for continued smoking or relapse. Indeed, by exacerbating illness, smoking itself is a stressor that the patient can take control over unlike other aspects of the cancer. Intensive cessation treatment for patients and survivors with high risk profiles for relapse (e.g., greater nicotine dependency, past or current depression) may have potential efficacy over brief treatments.

Disease and treatment variables may also influence smoking cessation. Patients with more advanced disease or those who receive more intensive treatments may have longer periods of hospitalization and enforced initial abstinence. Findings with hospitalized cancer patients indicate that smoking relapse is highest within the first month following hospital discharge.68 It appears that as survivors recuperate, begin to regain feelings of normalcy, and resume social routines such as work and family roles, the urge to smoke may increase. Patients who undergo less aggressive treatment with less functional disability, may be exposed to more smoking cues and in turn, a greater risk of relapse. In studies examining predictors of continued tobacco use following cancer,63,68patients who are diagnosed with less severe or early stage, curable disease and those who undergo relatively less intensive treatment regimens are less likely to quit smoking. Patients with early stage disease who have a good prognosis for survival may minimize the magnitude of ongoing health threats. Treatment and disease-related sequelae in cancer survivors can also serve to undermine smoking cessation interventions in cancer survivors. Treatment late effects, such as xerostomia (dry mouth) or surgical resections affecting the oral mucosa may result in the inability to produce saliva and use smoking cessation medications, including the nicotine gum or lozenge. Further, patients with gastrointestinal (GI) sequelae may not be able to use the nicotine lozenge or gum as it may worsen GI symptoms. The tailoring of pharmacologic therapies for tobacco dependence and the need for newer approaches that address these problems in cancer survivors are indicated.

For cancer patients, initial abstinence often occurs in the context of a restricted hospital environment in which patients are isolated from family, friends and co-workers who smoke. Given that smoking is a behavior that clusters in families, due in part to family modeling, behavioral norms, and genetic propensities, the social networks of cancer survivors are likely to include other smokers. Following hospital discharge, the presence of household smokers and other peers who smoke may pose significant barriers for successful maintenance of abstinence for the long-term. Living with a family member who smokes means repeated exposure to smoking cues in the home environment as well as ready access to tobacco products. Evidence among patients with head and neck cancers suggest that the presence of other household smokers, most commonly a patient's spouse, is a significant predictor of smoking resumption.63 Including family members in follow-up visits and taking time to encourage them to seek assistance for quitting is often necessary.

Cancer survivors may be reluctant to disclose their smoking status to health care providers or family members, a factor impeding the delivery and use of tobacco-dependence treatments. Much like pregnant smokers, cancer survivors may be reluctant to disclose their smoking status to their physicians due to fears ofstrong disapproval and criticism. Based on data from pregnant smokers documenting nondisclosure or under-reporting of quantity of smoking to health care providers,97,98 cancer survivors may also perceive nonsmoking expectations from health care providers.99 The usage of a structured question100 which serially assesses patterns of smoking reduction before, during, and after cancer diagnosis may enhance the accuracy of disclosure of smoking status by survivors.

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