Recruiting cancer patients to participate in motivating their relatives to quit smoking. A cancer control study of the Cancer and Leukemia Group B (CALGB 9072)

Guilt, censure, and concealment of active smoking status among cancer patients and family members after diagnosis: a nationwide study

OBJECTIVES

We aimed to identify the prevalence of feelings of guilt, censure, and concealment of smoking status among cancer patients and their family members who continued to smoke after the patient's diagnosis.

METHODS

Among 990 patient-family member dyads, 45 patients and 173 family members who continued to smoke for at least 1 month after the patients' diagnoses were administered questions examining feelings of guilt, censure, and smoking concealment.

RESULTS

Most patients who continued to smoke reported experiencing feelings of guilt toward their families (75.6%) and censure from their family members (77.8%), and many concealed their smoking from their family members (44.4%) or healthcare professionals (46.7%). Family members who continued to smoke also reported feelings of guilt with respect to the patient (63.6%) and that the patient was critical of them (68.9%), and many concealed their smoking from the patient (28.5%) or healthcare professionals (9.3%). Patients' feeling of guilt was associated with concealment of smoking from family members (55.9% vs. 10.0%) or health care professionals (55.9% vs. 20.0%). Family members who reported feeling guilty (36.5% vs. 16.3%) or censured (34.5% vs. 16.7%) were more likely to conceal smoking from patients.

CONCLUSION

Many patients and family members continue to smoke following cancer diagnosis, and the majority of them experience feelings of guilt and censure, which can lead to the concealment of smoking status from families or health care professionals. Feelings of guilt, censure, and concealment of smoking should be considered in the development and implementation of smoking cessation programs for cancer patients and family members.

Smoking Cessation Interventions and Cessation Rates in the Oncology Population

Objectives

To evaluate tobacco smoking cessation interventions and cessation rates in the oncology population through a systematic review and meta-analysis.

Data Sources

The literature was searched using PubMed, Google Scholar, Medline, EMBASE, and the Cochrane Library (inception to October 2012) by 3 independent review authors.

Review Methods

Studies were included if they were randomized controlled trials (RCTs) or prospective cohort (PCs) studies evaluating tobacco smoking cessation interventions with patients assigned to a usual care or an intervention group. The primary outcome measure was smoking cessation rates. Two authors extracted data independently for each study. When applicable, disagreements were resolved by consensus.

Results

The systematic review identified 10 RCTs and 3 PCs. Statistical analysis was conducted using StatsDirect software (Cheshire, UK). Pooled odds ratios (ORs) for smoking cessation interventions were calculated in 2 groups based on follow-up duration. The therapeutic interventions included counseling, nicotine replacement therapy, buproprion, and varenicline. Smoking cessation interventions had a pooled odds ratio of 1.54 (95% confidence interval [CI], 0.909-2.64) for patients in the shorter follow-up group and 1.31 (95% CI, 0.931-1.84) in the longer follow-up group. Smoking cessation interventions in the perioperative period had a pooled odds ratio of 2.31 (95% CI, 1.32-4.07).

Conclusion

Our systematic review and meta-analysis demonstrate that tobacco cessation interventions in the oncology population, in both the short-term and long-term follow-up groups, do not significantly affect cessation rates. The perioperative period, though, may represent an important teachable moment with regard to smoking cessation.

An evidence-based cessation strategy using rural smokers' experiences with tobacco

Little is known about the most effective strategies to motivate rural smokers to quit. This article describes the personal narratives of current and former smokers living in an economically distressed, rural area of Appalachian Kentucky. Three categories emerged: personal motivators to quit smoking, external influences, pride of place. Capturing personal narratives represents an evidence-based, data-rich strategy for development of culturally sensitive, population-based interventions for rural smokers. Such strategies may be effective in reaching rural smokers and motivating them to quit, thereby reducing tobacco-related disease and premature death in rural, economically distressed communities.

Smoking concordance in lung and colorectal cancer patient-caregiver dyads and quality of life

BACKGROUND

Distress may be heightened among members of cancer patient-caregiver dyads that are mismatched on smoking status (either the patient or caregiver smokes, but the other does not), negatively affecting quality of life (QoL). The purpose of this study was to examine associations between patient-caregiver smoking concordance, caregiver psychological adjustment, and caregiver and patient mental and physical QoL.

METHODS

Lung and colorectal patient-caregiver dyads (N = 742) were identified from the Cancer Care Outcomes Research and Surveillance (CanCORS) and CanCORS Caregiver studies. The majority of the cancer patients were male (67.0%) with local (45.6%) or regional (12.9%) disease. The majority of the informal caregivers were females (78.6%), under 65 years of age (69.6%), and often spouses (57.8%) of the patients.

RESULTS

Lung and colorectal cancer caregivers, who were members of dyads where one or both members continued to smoke, reported worse mental health QoL than nonsmoking dyads. For colorectal cancer patients, continuing to smoke when the caregiver did not was associated with worse mental health QoL compared with nonsmoking dyads. Dyad smoking was less strongly associated with physical QoL for both caregivers and patients.

CONCLUSION

Results highlight the importance of assessing smoking in both cancer patients and their caregivers and referring families to appropriate psychosocial and smoking cessation services.

IMPACT

This is the first study to show associations between cancer patient-caregiver smoking status and QoL for both dyad members. Future studies will need to confirm these associations longitudinally and investigate potential mechanisms linking dyad smoking and QoL.

Motivation to quit smoking among relatives of lung cancer patients

OBJECTIVE

The purpose of this study was to determine the factors related to motivation to quit among smoking family members of lung cancer patients.

DESIGN AND SAMPLE

Relatives of multidisciplinary lung cancer clinic patients were recruited during family members' treatment. Participants (N=29) were primarily female and Caucasian.

MEASURES

The items assessed included the effect of their relative's disease on motivation to quit, intent to quit in the next 6 months, stage of change, perceived risk from smoking, and attitudes about being approached about cessation.

RESULTS

Most indicated that their relative's disease had increased motivation to quit smoking (71%); 72% planned to quit within 6 months. One fourth (28%) were in precontemplation stage of change; 65% in contemplation; and 7% in preparation. The average perceived risk of developing lung cancer was 6.3. Two thirds were glad or very glad that someone had talked with them about quitting; 91% thought it was somewhat or very appropriate to talk about cessation with family members of lung cancer patients. Motivation to quit smoking was positively correlated with stage of change and perceived lung cancer risk.

CONCLUSIONS

Public health nurses who interact with families of lung cancer patients may be able to promote cessation in an at-risk group that is motivated to quit smoking.

Intention to quit smoking: role of personal and family member cancer diagnosis

Individuals who have ever experienced a cancer diagnosis and their family members may be priority audiences for health improving interventions. Guided by the heuristic model of the 'teachable moment' and using data from the 2003 National Cancer Institute's Health Information National Trends Survey, we explored whether having a lifetime history of cancer or having a family member with a lifetime history of cancer was associated with intention to quit smoking. Results showed that having a personal lifetime history of cancer was not associated with intention to quit, while having a family member with a lifetime history of cancer was (χ(2) = 7.08, P < 0.01). Path analysis showed that individual perceived risk of cancer mediated the relationship between having a family member with a history of cancer and quitting intention: smokers who had a family member with a history of cancer in addition to an elevated level of perceived cancer risk were 36% more likely to report intending to quit. These preliminary data suggest that family members of cancer patients may be a viable target population for smoking cessation interventions, especially when they have heightened levels of perceived cancer risk. An adequately powered, controlled trial is needed to fully evaluate this hypothesis.

"Just because you've got lung cancer doesn't mean I will": lung cancer, smoking, and family dynamics

Although individuals who are diagnosed with smoking-related disorders are offered smoking cessation programs, little attention has been directed toward reducing tobacco use among healthy relatives who smoke. The purpose of this article is to report smoking relatives' responses to a family member's diagnosis of lung disease, their constructions of smoking in this context, and their interaction patterns with the patient. Interviews with 11 family members where there was a diagnosis of lung cancer and 3 family members where there was another serious smoking-related diagnosis were analyzed. Family members used two strategies to support their continued smoking: distancing themselves from the diagnosis and taking the position that smoking cessation needed to be internally motivated by the "right reason" and initiated at the "right time" to anticipate success. The few participants who chose to quit, did so in support of their ill family member. The findings provide direction for intervening with family members who smoke.

Willingness of cancer patients to help family members to quit smoking

OBJECTIVES

The impact of social support on successful smoking cessation has been well documented. However, little is known about whether personal experience with cancer may motivate cancer survivors to support smoking cessation among their family members and friends. As a first step in this line of research, we sought to explore interest in playing a supportive role for smoking cessation as well as correlates of such interest among cancer survivors.

METHODS

Cancer survivors undergoing radiation therapy (N=211) completed a 77-item pencil-paper questionnaire. A section of the survey assessed interest in helping a smoker quit and characteristics of the smoking social network member. Respondents provided information on their smoking status, medical status, and psychosocial and behavioral factors related to cigarette smoking.

RESULTS

Over half of the respondents 114 (54%) reported having someone close to them (family member or friend) smoking cigarettes who they thought should quit. Of these respondents (44 females, 70 males) 78% (89/114) reported they were definitely or probably interested in helping a smoker quit. Nearly all respondents wanted to help a family member (typically an adult child).

CONCLUSIONS

Results suggest the potential feasibility of engaging cancer survivors to help family members quit smoking. Research is needed to determine the optimal methods and timing for engaging the cancer patient to maximize positive effects and minimize potential harms.

Smoking cessation interventions in cancer care: opportunities for oncology nurses and nurse scientists

Smoking cessation is essential after the diagnosis of cancer to improve clinical outcomes. The purpose of this chapter is to provide a systematic review of research on smoking cessation in the context of cancer care with an emphasis on nursing contributions to the field. Data sources included research reports of smoking cessation interventions conducted in people with cancer. Nineteen primary studies were reviewed. High intensity interventions, targeting multiple behaviors, and/or using a multicomponent intervention that included pharmacotherapy, behavioral counseling, and social support were characteristics of the most successful treatments for tobacco dependence. The majority of interventions were conducted in adults with smoking-related malignancies during acute phases of illness. The most striking finding was that more than one half of the studies tested the efficacy of nurse-delivered interventions. Conceptual and methodological issues that can be improved in future studies include: using theoretical frameworks to specify how the intervention will affect outcomes, ensuring adequate sample sizes, using biochemical verification to monitor smoking outcomes, and using standardized outcome measures of abstinence. Although effective interventions are available for healthy populations, further research is needed to determine if tailored cessation interventions are needed for patients with cancer. To provide optimal quality care it is imperative that delivery of evidence-based smoking cessation interventions be integrated into the cancer treatment trajectory. Multiple barriers, including patient and nurse attitudes toward smoking and lack of knowledge related to tobacco treatment, prevent translating evidence-based tobacco dependence treatment into clinical practice. Further nursing research is needed to address these barriers.

The feasibility of online genetic testing for lung cancer susceptibility: uptake of a web-based protocol and decision outcomes

PURPOSE

To examine the feasibility of offering genetic susceptibility testing for lung cancer (GSTM1) via the Internet to smokers who were blood relatives of patients with lung cancer. Outcomes include proportion who logged on to the study website to consider testing, made informed decisions to log on and to be tested.

METHODS

Baseline measures were assessed via telephone survey. Participants could choose to log on to the study website; those who did were offered testing. Informed decisions to log on and to be tested were indicated by concordance between the decision outcome and test-related attitudes and knowledge.

RESULTS

Three hundred four relatives completed baseline interviews. One hundred sixteen eligible relatives expressed further interest in receiving information via the web. Fifty-eight logged on and 44 tested. Those logging on expressed greater quit motivation, awareness of cancer genetic testing, and were more likely to be daily Internet users than those who did not log on. Approximately half of the sample made informed decisions to log on and to be tested.

CONCLUSION

Interest in a web-based protocol for genetic susceptibility testing was high. Internet-delivered decision support was as likely as other modalities to yield informed decisions. Some subgroups may need additional support to improve their decision outcomes.

Tobacco use in women with lung cancer

BACKGROUND

Smoking cessation after a cancer diagnosis is associated with improved clinical outcomes.

PURPOSE

The aims of this study are to determine smoking prevalence, describe patterns of smoking, identify readiness to quit and cessation strategies, identify factors associated with continued smoking among women with lung cancer, and determine smoking prevalence among household members.

METHODS

Data were collected through questionnaires and medical record review from 230 women. Smoking was determined through self-report and biochemical verification with urinary cotinine.

RESULTS

Eighty-seven percent of women reported ever-smoking, and 37% reported smoking at the time of diagnosis. Ten percent of women were smoking at entry to the study, 13% were smoking at 3 months, and 11% at 6 months. Fifty-five percent of smokers planned a quit attempt within the next month. One third of smokers received cessation assistance at diagnosis, and pharmacotherapy was the most common strategy. Significant factors associated with continued smoking included younger age, depression, and household member smoking. Continued smoking among household members was 21%. Twelve percent of household members changed their smoking behavior; 77% quit smoking, but 12% started smoking.

CONCLUSIONS

The diagnosis of cancer is a strong motivator for behavioral change, and some patients need additional support to quit smoking. Family members should also be targeted for cessation interventions.

Skin cancer risk discussions in melanoma-affected families

BACKGROUND

First-degree relatives (FDRs) of melanoma patients are at increased melanoma risk and thus represent an important target for prevention education. Family skin cancer risk discussions may be a useful education context.

METHODS

We assessed melanoma patients' (N = 115) self-reported family skin cancer risk discussions and changes in FDRs' prevention strategies.

RESULTS

Melanoma patients overwhelmingly (94%) reported risk discussions, primarily to communicate about melanoma prevention. These discussions occurred most frequently with patients' children (36%). Nearly half (46%) of household FDRs increased their melanoma prevention and control behaviors.

CONCLUSIONS

This study attests to the potential to engage melanoma-affected families in prevention education.

Teachable moments for promoting smoking cessation: the context of cancer care and survivorship

BACKGROUND

There has been a call for comprehensive cancer care that gives greater consideration to changing lifestyle risk factors such as smoking to improve prognosis and long-term health. Cancer diagnosis, treatment, and survivorship offer challenges and opportunities ("teachable moments") to promote smoking cessation.

METHODS

This review provides a rationale for the importance of smoking cessation programs in the cancer context, highlights practice guidelines for the delivery of these interventions, summarizes the challenges to smoking cessation unique to cancer patients, and recommends approaches to capitalize on the cancer context to promote smoking cessation.

RESULTS

Barriers to smoking cessation by patients with cancer include heavy nicotine dependence, urgency of cessation, fatalistic attitudes about cessation benefits, cancer-related psychological distress, treatment factors, and the presence of smokers in the social network. Opportunities to promote cessation include the transition from inpatient to outpatient care, involvement in cancer patient care by family members who smoke, and distribution of clinical feedback (eg, test results).

CONCLUSIONS

Teachable moments in the cancer context are not being fully utilized to promote smoking cessation. Evidence-based guidelines can assist cancer care teams in promoting cessation.

Distress and motivation for smoking cessation among lung cancer patients' relatives who smoke

BACKGROUND

Heightened distress at the time of a loved one's lung cancer diagnosis may motivate relatives to quit smoking or could undermine cessation.

METHODS

Relatives of new lung cancer patients at Duke were surveyed by telephone to assess diagnosis-related depression, distress, and motivation for smoking cessation.

RESULTS

Relatives who reported above average avoidant and intrusive thinking patterns, depressive symptoms or worry were more likely to report that the patient's diagnosis increased their intentions to quit than the less distressed.

CONCLUSIONS

Interventions are needed that encourage smoking cessation as a strategy for adaptively coping with a loved ones' lung cancer diagnosis.

Tobacco use outcomes among patients with lung cancer treated for nicotine dependence

PURPOSE

There is a current lack of consensus about the effectiveness of nicotine dependence treatment for cancer patients. This retrospective study examined the 6-month tobacco abstinence rate among lung cancer patients treated clinically for nicotine dependence.

PATIENTS AND METHODS

A date-of-treatment matched case control design was used to compare lung cancer patients (201 lung cancer patients, 41% female) and nonlung cancer patients (201 controls, 45% female) treated in the Mayo Clinic Nicotine Dependence Center between 1988 and 2000. The intervention involves a brief consultation with a nicotine dependence counselor. A treatment plan individualized to the patient's needs is then developed. The primary end point was the self-reported, 7-day point prevalence abstinence from tobacco at 6-month follow-up.

RESULTS

At baseline, compared with the controls, the lung cancer patients were significantly older (P <.001), reported higher motivation to stop smoking (P =.003), and were at a higher stage of change (P =.002). The 6-month tobacco abstinence rate was 22% for the lung cancer patients compared with 14% of the control patients (P =.024). After adjusting for age, sex, baseline cigarettes smoked per day, and stage of change, no significant difference was detected between lung cancer patients and controls on the tobacco abstinence rate.

CONCLUSION

The results suggest that nicotine dependence treatment is effective for patients with a diagnosis of lung cancer. The majority of lung cancer patients were motivated to stop smoking.

Adherence to recommendations for clinical follow-up after benign breast biopsy

PURPOSE

Women who undergo a benign breast biopsy are at elevated risk for the subsequent development of breast cancer (BC). Therefore, appropriate clinical follow-up of a benign breast biopsy is important. The present study examines the extent and correlates of nonadherence with follow-up recommendations after a benign breast biopsy.

METHODS

Women (n = 114) who had undergone a benign breast biopsy completed an initial telephone interview within 50 days of their biopsy (mean = 21 days). Additional telephone interviews were completed at 4 and 8 months post-biopsy. Measures of BC risk perception, general and BC-specific distress, BC-related attitudes and beliefs, social support, optimism, and informational coping style were completed. Specific recommendations for clinical follow-up and evidence of actual follow-up were obtained from medical records.

RESULTS

Of 103 women given a specific recommendation for clinical follow-up, 34% were classified as nonadherent with follow-up recommendations. Logistic regression analyses indicated that nonadherent women were characterized by younger age, recommendations for follow-up by clinical breast examination alone, greater confidence in their ability to perform breast self-examination properly, higher perceived personal risk for BC, and greater BC-specific distress.

CONCLUSION

Despite the importance of appropriate clinical follow-up of a benign breast biopsy, about one-third of women did not adhere to recommended follow-up. Risk factors for nonadherence suggest potential avenues for interventions to enhance participation in appropriate clinical follow-up.

Prevention: tobacco control and cancer nursing

In the next century, tobacco will become the number-one cause of preventable death throughout the world, resulting in half a billion deaths. As global patterns of tobacco use change, tobacco-related morbidity and mortality will shift from developed countries to developing countries. Internationally, lung cancer will become the fifth leading cause of preventable death, affecting an increasing number of women. Tobacco cessation after a diagnosis of cancer may decrease treatment-related morbidity and increase survival. With the increasing number of cancer survivors, tobacco cessation becomes an important part of rehabilitation. This article aims to provide a foundation for developing strategies to involve cancer nurses throughout the world in an international campaign to prevent tobacco-related morbidity and mortality. The devastating health impacts of tobacco are reviewed, and highlights of new scientific findings about nicotine addiction are presented. New approaches to tobacco prevention, legislation, and regulatory policies are discussed. Tobacco assessment strategies and treatment interventions for use in cancer nursing clinical practice are reviewed, and global strategies for nursing action in tobacco control are offered.