Continuing to smoke after a cancer diagnosis

By J. Lee Westmaas, PhD

While the American Cancer Society and other organizations traditionally focus on getting smokers to quit before they develop cancer, there’s a group of smokers who are especially susceptible to the negative effects of smoking. They are cancer survivors – some of whom have been diagnosed with a smoking-related cancer. It’s easy to say, “If you get cancer, then you should know better and quit, and stay quit,” but that’s not the whole story.

Getting a cancer diagnosis does motivate some smokers to quit. Using data from the American Cancer Society Cancer Prevention Study-II, we found that about 1 out of 3 smokers quit smoking when they were diagnosed with cancer. That compares with only 1 out of 5 smokers who quit but were not diagnosed with cancer during the same time periods studied.

Even smokers whose cancer was not strongly linked to smoking (like breast cancer) quit at higher rates than undiagnosed smokers. These results were not caused by the smokers being unable to smoke due to their illness; those people were excluded from the study.

Smoking: Risky for patients and survivors

Quitting is particularly important for cancer patients and survivors because smoking can increase the likelihood of a recurrence, delay wound healing, and make cancer treatments less effective. This is true even for cancers that aren’t related to smoking. 

Unfortunately, there are some cancer survivors who find it very hard to quit. We looked at data from the Study of Cancer Survivors (SCS-I), a nationwide quality-of-life study conducted by the Behavioral Research Center at the American Cancer Society. The study surveyed 2,938 survivors of 10 different kinds of cancers approximately 9 years after their initial diagnosis.

We found that 9.3% of these survivors were current smokers. Survivors of bladder, lung, and ovarian cancers had the highest smoking rates in this study. Most (83%) current smokers smoked daily, averaging almost 15 cigarettes per day. In fact, 40% percent of daily smokers smoked more than 15 cigarettes per day. [more]

We think part of the problem is that cancer survivors who smoke are not being asked about their smoking habits by healthcare providers, and therefore not being told of the risks. Those who want to quit may not be getting the help they need, or they may think it’s too difficult or expensive to get help like individual or group counseling, nicotine replacement therapies, and/or medicines for quitting smoking. Many smokers, including cancer survivors, may not even know that there’s a free 1-800-QUIT-NOW telephone counseling line they can use. Some hospitals have free or low-cost quit smoking programs, too.

About half of the current smokers in the study indicated they were planning to quit, some of them within the next month. This suggests that they are thinking about the risks of smoking, and they want to reduce their risk. Survivors intending to quit (vs. those not intending or unsure) rated the negative health effects of smoking as more severe, they saw fewer benefits from smoking, and they reported greater social pressure to quit.

Tailoring quitting treatments to cancer survivors

I think the important message is that we continue to ask about cancer survivors’ smoking status, and try to make sure that treatment for quitting is available to them well after their initial diagnosis. It’s important to make it easy for them to access these treatments, too.

Quit-smoking programs for cancer survivors may also need to be tailored to the kinds of issues they may be facing as cancer survivors. For instance, some may be experiencing anxiety and depression, and some may have memory or concentration problems or cognitive impairment, all of which can make quitting more difficult.

Lung cancer survivors might also be dealing with feelings of guilt, shame, and stigmatization by people who blame them for causing their cancer. These negative emotions can make it even more difficult to quit. So helping lung cancer survivors quit smoking needs to address these emotions, and provide ways of coping with them.  

The type of quit-smoking medicines used can also play a role here. One study found that the antidepressant bupropion (also known as Zyban) was more effective in helping depressed cancer survivors quit smoking, compared to survivors who were not depressed. Varenicline (known as Chantix) is also looking to be a very promising cessation treatment for cancer survivors, with even higher quit rates compared to other medicines or interventions.

If there is greater attention paid to smoking among cancer survivors, more programs will be developed that are tailored to the unique histories and experiences of cancer survivors. For example, my colleagues at H. Lee Moffitt cancer center are testing a program for cancer survivors who quit smoking to help keep them from starting up again. It consists of booklets sent periodically to remind survivors about the importance of staying quit, and strategies and resources for helping them if they relapse.

We recently tested a program here at the American Cancer Society that we plan to adapt for cancer survivors. It’s an email program that uses information provided by the smoker (e.g., triggers, reasons for quitting, social supports, etc.) to send personalized, tailored information and advice before, during, and after a quit attempt. Preliminary results in the general population of smokers showed that this intervention increased the number of days smokers avoided smoking. With input from cancer survivors, we hope to develop a version that we can then test and make available for free to cancer survivors.

With the appropriate level of support and encouragement, along with inexpensive, easy-to-access resources, all smokers, including cancer survivors, should be able to take advantage of the latest treatments to help them quit.

Dr. Westmaas is director of tobacco research for the American Cancer Society.

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