Longitudinal associations between smoking and affect among cancer patients using varenicline to quit smoking

A qualitative study of attitudes and perceptions of smoking cessation medication among patients with cancer

PURPOSE

Among patients with cancer, tobacco use remains high. Nearly half who report smoking at diagnosis continue to smoke following diagnosis, and use of smoking cessation medication remains low. This study explores attitudes, barriers, and preferences for smoking cessation medication among patients enrolled in a tobacco treatment trial in the context of cancer care.

METHODS

This is a secondary qualitative analysis of the Smokefree Support Study. Of 221 participants who completed the 6-month follow-up survey, n = 72 participants were randomly selected for an exit interview. Interviews were conducted using a semi-structured interview guide, recorded, transcribed, and individually coded using NVivo 11 until high interrater reliability was reached (Kappa > 0.86).

RESULTS

Participants (55.6% female) were predominantly White (83.3%) and on average 60 years old. Many participants held negative beliefs about smoking cessation medications, primarily concerns about safety and side effects in the context of cancer treatment. Lack of understanding interactions with ongoing chemotherapy and access were the most common barriers reported by those who did not use cessation medication during the study. For those who did use medication during the study, positive outcomes included craving reduction, ease of use and access, and psychological benefits.

CONCLUSION

The findings suggest a knowledge gap in the safety and effectiveness of smoking cessation medications, specifically in relation to cancer care. Addressing this knowledge gap may increase medication uptake, adherence, and quit rates. Cancer care providers are seen as instrumental in emphasizing the importance and safety of smoking cessation medications as well as patient access concerns.

IMPLICATIONS

Tobacco use among patients with cancer remains high and has serious clinical implications. Tobacco cessation is associated with decreased treatment-related toxicity, decreased risk of second primary cancers, and increased survival rates. Smoking cessation medications are effective, yet patients with cancer have low usage rates. Elucidating reasons associated with smoking cessation medication nonadherence will assist cancer care providers in better addressing factors that increase adherence rates.

Systematic Review of Smoking Cessation Interventions for Smokers Diagnosed with Cancer

The detrimental impact of smoking on health and wellbeing are irrefutable. Additionally, smoking is associated with the development of cancer, a reduction treatment outcomes and poorer health outcomes. Nevertheless, a significant number of people continue to smoke following a cancer diagnosis. Little is understood of the smoking cessation services provided to smokers with cancer or their engagement with them. This systematic review aimed to identify existing smoking cessation interventions for this cohort diagnosed with breast, head and neck, lung and cervical cancers (linked to risk). Systematic searches of Pubmed, Embase, Psych Info and CINAHL from 1 January 2015 to 15 December 2020 were conducted. Included studies examined the characteristics of smoking cessation interventions and impact on referrals and quit attempts. The impact on healthcare professionals was included if reported. Included studies were restricted to adults with a cancer diagnosis and published in English. No restriction was placed on study designs, and narrative data synthesis was conducted due to heterogeneity. A review protocol was registered on PROSPERO CRD 42020214204, and reporting adheres to PRISMA reporting guidelines. Data were screened, extracted in duplicate and an assessment of the quality of evidence undertaken using Mixed Methods Assessment Tool. 23 studies met the inclusion criteria, representing USA, Canada, England, Lebanon, Australia and including randomized controlled trials (9), observational studies (10), quality improvement (3), and one qualitative study. Hospital and cancer clinics [including a dental clinic] were the settings for all studies. 43% (10/23) of studies reported interventions for smokers diagnosed with head and neck cancer, 13% (3/23) for smokers diagnosed with lung cancer, one study provides evidence for breast cancer, and the remaining nine studies (39%) report on multiple cancers including the ones specified in this review. Methodological quality was variable. There were limited data to identify one optimal intervention for this cohort. Key elements included the timing and frequency of quit conversations, use of electronic records, pharmacotherapy including extended use of varenicline, increased counselling sessions and a service embedded in oncology departments. More studies are required to ensure tailored smoking cessation pathways are co-developed for smokers with a diagnosis of cancer to support this population.

The effects of emotion dysregulation and negative affect on urge to smoke and nicotine dependence: The different roles of metacognitions about smoking

Evidence has shown that smoking is a self-regulatory strategy to relieve negative affect and that metacognitions about smoking may play a role in addictive behaviors. Therefore, the present research was designed to examine the direct and indirect roles of emotion dysregulation and negative affect in predicting urge to smoke and nicotine dependence via metacognitions about smoking. In a cross-sectional study, 450 nicotine-dependent men completed measures of urge to smoke, nicotine dependence, metacognitions about smoking, negative affect, and emotion dysregulation. The results showed that both emotion dysregulation and negative affect had indirect effects on urge to smoke via positive metacognitions about smoking as well as on nicotine dependence via negative metacognitions about smoking. The findings suggest that metacognitions about smoking have different roles in different patterns of nicotine use so that positive and negative metacognitions have important roles respectively in urge to smoke and nicotine dependence in smokers with high emotion dysregulation and negative affect. This study also adds to the literature on the metacognitive theoretical framework of addictive behaviors supporting the use of Metacognitive Therapy interventions in smoking cessation.

Smoking cessation for improving mental health

BACKGROUND

There is a common perception that smoking generally helps people to manage stress, and may be a form of 'self-medication' in people with mental health conditions. However, there are biologically plausible reasons why smoking may worsen mental health through neuroadaptations arising from chronic smoking, leading to frequent nicotine withdrawal symptoms (e.g. anxiety, depression, irritability), in which case smoking cessation may help to improve rather than worsen mental health.

OBJECTIVES

To examine the association between tobacco smoking cessation and change in mental health.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, and the trial registries clinicaltrials.gov and the International Clinical Trials Registry Platform, from 14 April 2012 to 07 January 2020. These were updated searches of a previously-conducted non-Cochrane review where searches were conducted from database inception to 13 April 2012.  SELECTION CRITERIA: We included controlled before-after studies, including randomised controlled trials (RCTs) analysed by smoking status at follow-up, and longitudinal cohort studies. In order to be eligible for inclusion studies had to recruit adults who smoked tobacco, and assess whether they quit or continued smoking during the study. They also had to measure a mental health outcome at baseline and at least six weeks later.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Our primary outcomes were change in depression symptoms, anxiety symptoms or mixed anxiety and depression symptoms between baseline and follow-up. Secondary outcomes  included change in symptoms of stress, psychological quality of life, positive affect, and social impact or social quality of life, as well as new incidence of depression, anxiety, or mixed anxiety and depression disorders. We assessed the risk of bias for the primary outcomes using a modified ROBINS-I tool.  For change in mental health outcomes, we calculated the pooled standardised mean difference (SMD) and 95% confidence interval (95% CI) for the difference in change in mental health from baseline to follow-up between those who had quit smoking and those who had continued to smoke. For the incidence of psychological disorders, we calculated odds ratios (ORs) and 95% CIs. For all meta-analyses we used a generic inverse variance random-effects model and quantified statistical heterogeneity using I2. We conducted subgroup analyses to investigate any differences in associations between sub-populations, i.e. unselected people with mental illness, people with physical chronic diseases. We assessed the certainty of evidence for our primary outcomes (depression, anxiety, and mixed depression and anxiety) and our secondary social impact outcome using the eight GRADE considerations relevant to non-randomised studies (risk of bias, inconsistency, imprecision, indirectness, publication bias, magnitude of the effect, the influence of all plausible residual confounding, the presence of a dose-response gradient).

MAIN RESULTS

We included 102 studies representing over 169,500 participants. Sixty-two of these were identified in the updated search for this review and 40 were included in the original version of the review.  Sixty-three studies provided data on change in mental health, 10 were included in meta-analyses of incidence of mental health disorders, and 31 were synthesised narratively.  For all primary outcomes, smoking cessation was associated with an improvement in mental health symptoms compared with continuing to smoke: anxiety symptoms (SMD -0.28, 95% CI -0.43 to -0.13; 15 studies, 3141 participants; I2 = 69%; low-certainty evidence); depression symptoms: (SMD -0.30, 95% CI -0.39 to -0.21; 34 studies, 7156 participants; I2 = 69%' very low-certainty evidence);  mixed anxiety and depression symptoms (SMD -0.31, 95% CI -0.40 to -0.22; 8 studies, 2829 participants; I2 = 0%; moderate certainty evidence).  These findings were robust to preplanned sensitivity analyses, and subgroup analysis generally did not produce evidence of differences in the effect size among subpopulations or based on methodological characteristics. All studies were deemed to be at serious risk of bias due to possible time-varying confounding, and three studies measuring depression symptoms were judged to be at critical risk of bias overall. There was also some evidence of funnel plot asymmetry. For these reasons, we rated our certainty in the estimates for anxiety as low, for depression as very low, and for mixed anxiety and depression as moderate. For the secondary outcomes, smoking cessation was associated with an improvement in symptoms of stress (SMD -0.19, 95% CI -0.34 to -0.04; 4 studies, 1792 participants; I2 = 50%), positive affect (SMD 0.22, 95% CI 0.11 to 0.33; 13 studies, 4880 participants; I2 = 75%), and psychological quality of life (SMD 0.11, 95% CI 0.06 to 0.16; 19 studies, 18,034 participants; I2 = 42%). There was also evidence that smoking cessation was not associated with a reduction in social quality of life, with the confidence interval incorporating the possibility of a small improvement (SMD 0.03, 95% CI 0.00 to 0.06; 9 studies, 14,673 participants; I2 = 0%). The incidence of new mixed anxiety and depression was lower in people who stopped smoking compared with those who continued (OR 0.76, 95% CI 0.66 to 0.86; 3 studies, 8685 participants; I2 = 57%), as was the incidence of anxiety disorder (OR 0.61, 95% CI 0.34 to 1.12; 2 studies, 2293 participants; I2 = 46%). We deemed it inappropriate to present a pooled estimate for the incidence of new cases of clinical depression, as there was high statistical heterogeneity (I2 = 87%).

AUTHORS' CONCLUSIONS

Taken together, these data provide evidence that mental health does not worsen as a result of quitting smoking, and very low- to moderate-certainty evidence that smoking cessation is associated with small to moderate improvements in mental health.  These improvements are seen in both unselected samples and in subpopulations, including people diagnosed with mental health conditions. Additional studies that use more advanced methods to overcome time-varying confounding would strengthen the evidence in this area.

Negative affect among daily smokers: A systematic review and meta-analysis

BACKGROUND

Negative Affect (NA), as a personality trait is a tendency towards experiencing a more negative emotion. The body of research suggests that NA encourages smoking relapse and smoking as a reason for NA reduction, though. The likelihood of this connection does not seem to be bright yet. The present study critically reviews researches to synthesize the existing literature to determine the strength of this linkage.

METHODS

Key-word related research was systematically searched in PubMed, PsychINFO, Science Direct and Google Scholar for studies conducted from 1980 to 2019, followed by, the assessment and selection of retrieved studies based on defined inclusion criteria. A random-effects meta-analysis model was used to examine the prospective relationship between NA and smoking. Meta-regression was also used to dig for possible explanations of heterogeneity. Furthermore a multi-moderators model and sub-group analyses examined the moderating factors.

RESULTS

Forty effect-sizes comprising 12 cross-sectional studies, 28 longitudinal studies and 24,913 participants were included in the meta-analysis. The forest plot of the pooled correlation effect size in the random model indicates a significant effect size of the relationship between NA and smoking (r = 0.11; 95%CI 0.071-0.15, P = 0.001) in the meta-analysis with high heterogeneity (Q = 473.916; df=39; P = 0.001; I²=91.77%). Also, the pooled effect size was obtained as 0.143 (95%CI 0.071-0.214) for light-to-moderate and 0.112 (95%CI 0.057-0.166) for moderate-to-heavy smokers, with the effect size ranging from 0.061 to 0.195 which was significant among all subtypes, though this trend seem higher among adolescents, males, and longitudinal studies than in adults, females, and cross-sectional studies.

LIMITATIONS

The review was limited to English articles, and the heterogeneity of the studies were high.

CONCLUSION

These results support the notion that NA was positively and weakly linked to smoking and this linkage is stronger in light-to-moderate smokers, males, and adolescents. Theoretical and clinical implications are discussed with the aim of extending future directions on NA and smoking.

Design and Pilot Implementation of an Electronic Health Record-Based System to Automatically Refer Cancer Patients to Tobacco Use Treatment

Continued tobacco use after cancer diagnosis is detrimental to treatment and survivorship. The current reach of evidence-based tobacco treatments in cancer patients is low. As a part of the National Cancer Institute Cancer Center Cessation Initiative, the Mayo Clinic Cancer Center designed an electronic health record (EHR, Epic^©)-based process to automatically refer ambulatory oncology patients to tobacco use treatment, regardless of intent to cease tobacco use(“opt out”). The referral and patient scheduling, accomplished through a best practice advisory (BPA) directed to staff who room patients, does not require a co-signature from clinicians. This process was piloted for a six-week period starting in July of 2019 at the Division of Medical Oncology, Mayo Clinic, Rochester, MN. All oncology patients who were tobacco users were referred for tobacco treatment by the rooming staff (n = 210). Of these, 150 (71%) had a tobacco treatment appointment scheduled, and 25 (17%) completed their appointment. We conclude that an EHR-based “opt-out” approach to refer patients to tobacco dependence treatment that does not require active involvement by clinicians is feasible within the oncology clinical practice. Further work is needed to increase the proportion of scheduled patients who attend their appointments.