The Validity of Self-reported Recent Smoking in Head and Neck Cancer Surgical Patients

Assessing tobacco use in Swedish young adults from self-report and urinary cotinine: a validation study using the BAMSE birth cohort

OBJECTIVES

Studies on health effects of tobacco often rely on self-reported exposure data, which is subjective and can lead to misclassification. The aim of this study was to describe the prevalence of cigarette smoking, snus and e-cigarette use, as well as to validate self-reported tobacco use among young adults in Sweden.

METHOD

Participants of a population-based Swedish cohort (n=3052), aged 22-25 years, assessed their tobacco use in a web questionnaire. Urinary cotinine was analysed in a subsample of the study population (n=998). The agreement between self-reported tobacco use and urinary cotinine was assessed using Cohen's Kappa coefficient (κ) at a cut-off level of 50 ng/mL.

RESULTS

Patterns of tobacco use differed between men and women. Among men, 20.0% reported daily snus use, 5.8% daily cigarette smoking and 5.6% any e-cigarette use. In contrast, 3.2% of the women reported daily snus use, 9.0% daily cigarette smoking and 2.4% any e-cigarette use. Among the tobacco use categories, daily snus users had the highest levels of cotinine. Of reported non-tobacco users, 3.5% had cotinine levels above the cut-off, compared with 68.0% among both occasional cigarette smokers and snus users, 67.5% among all e-cigarette users and 94.7% and 97.8% among daily cigarette smokers and snus users, respectively. Agreement between self-reported tobacco use and urinary cotinine was classified as strong for daily use of cigarettes (κ=0.824) and snus (κ=0.861), while moderate to weak for occasional smoking (κ=0.618), occasional snus use (κ=0.573) and any e-cigarette use (κ=0.576).

CONCLUSIONS

We found high validity of self-reported tobacco use in our study population, particularly for daily tobacco use. Further, we found that daily snus users were exposed to high levels of cotinine. Together with previous findings, our results indicate good validity of self-reported tobacco use among young adults.

Determinants of tobacco smoking abstinence 1 year after major noncardiac surgery: a secondary analysis of the VISION study

BACKGROUND

Tobacco smoking is a leading preventable cause of death and increases perioperative risk. Determinants of smoking abstinence after noncardiac surgery and the association between smoking and 1-yr vascular outcomes are not fully elucidated.

METHODS

We did a prospective cohort study of 40 004 patients, aged ≥45 yr, enrolled between August 2007 and November 2013, and followed for 1 yr after surgery. Patients were categorised as never smokers, ex-smokers (quit >4 weeks preoperatively), and current smokers (smoking ≤4 weeks preoperatively). Primary outcome was abstinence at 1 yr. Secondary outcome was a composite of all-cause death, non-fatal myocardial infarction, and non-fatal stroke at 1 yr.

RESULTS

Of 4658 current smokers, 1838 (39.5%) were abstinent 1 yr after surgery. Median (inter-quartile range) time to resumption was 7 (3-23) days post-surgery. Perioperatively, 7.2% of current smokers obtained smoking cessation pharmacotherapy. Older age (adjusted risk ratio [aRR] 1.21; 95% confidence interval [CI]: 1.12-1.32); having recent coronary artery disease (aRR 1.41; 95% CI: 1.29-1.55); cancer (aRR 1.37; 95% CI: 1.18-1.59); and undergoing major vascular (aRR 1.20; 95% CI: 1.02-1.41), urgent/emergent (aRR 1.14; 95% CI: 1.05-1.23), or thoracic (aRR 1.41; 95% CI: 1.26-1.56) surgeries increased abstinence. One-year abstinence was less likely when patients stopped smoking 0-1 day (aRR 0.53; 95% CI: 0.43-0.66) and 2-14 days (aRR 0.76; 95% CI: 0.71-0.82) before surgery compared with >14 days before surgery. Current smokers (adjusted hazard ratio [aHR] 1.14; 95% CI: 1.01-1.29) and ex-smokers (aHR 1.11; 95% CI: 1.03-1.21) had higher risk of the 1-yr vascular outcome compared with never smokers.

CONCLUSIONS

Long-term tobacco abstinence is more likely after major surgery in those with serious medical comorbidities. Interventions to prevent smoking resumption after surgery remain a priority. Clinical trial registration NCT00512109.

Smoking and other health factors in patients with head and neck cancer

BACKGROUND

Information on smoking and other health factors in head and neck cancer (HNC) patients throughout treatment, follow-up and survivorship is limited. This study explores patterns of multiple health factors during radiotherapy (RT) and naturalistic long-term follow-up in a convenience sample of patients with HNC.

METHODS

Smoking, alcohol use and depression were measured at baseline, 4 and 12 weeks post RT for a sub-group of 99 patients who participated in a randomised controlled trial and completed long-term follow-up. These factors plus healthy eating, physical activity and fatigue are also reported from the long-term follow-up component. Smoking was measured by self-report and biochemically, whilst all other variables were by self-report. Where variables were assessed at multiple time points logistic mixed effects regression models determined within-person changes over time.

RESULTS

There were important discrepancies between self-reported (4-7%) and biochemically verified (13-29%) rates of smoking. Rates of smoking and hazardous alcohol intake were significantly increased at follow-up compared to baseline. Depression rates were observed to be higher at end of RT compared to baseline. At long-term follow-up, fatigue was common and co-occurred with suboptimal healthy eating and hazardous alcohol use.

CONCLUSION

Clinically important levels of smoking and alcohol consumption post RT in this sample suggest possible targets for intervention beyond treatment into long-term follow-up of patients.

Tobacco use in patients with ENT tumours: Deficits in the provision of education and smoking cessation support

PURPOSE

Smoking is not only one of the main risk factors for the development of most malignant and numerous benign ENT tumours but also has an important influence on therapy and prognosis. Even quitting smoking at the time of diagnosis significantly reduces mortality. Patients have a particularly strong desire to stop smoking when they are diagnosed. The present study investigated to what extent patients were aware of the relationships between smoking and the development and prognosis of tumours and how much information and smoking cessation support they were offered by physicians.

METHODS

A total of 194 patients (74.7% male, 62.0 ±10.6 a) with malignant primary ENT tumours, pre-cancerous tumours, Reinke's oedema and salivary gland tumours were interviewed.

RESULTS

22.7% were nonsmokers, 49.5% were cigarette smokers and 27.8% were ex-smokers. A total of 57.0% of the smokers said they would have quit before the onset of the disease if they had known about the association. Forty-one percent did not receive information about the association between smoking and the development of their disease, while 45.5% did not receive information about the relationship with their prognosis. The provision of information lasted less than 5 min for 40.4% of the patients and more than 10 min for only 13.5%. In total, 50.7% of the patients were directly requested not to smoke. A total of 7.7% received offers of smoking cessation support from otolaryngologists and 18.2% received such offers from family physicians.

CONCLUSIONS

There is a pronounced need for improvements in the provision of medical information about the health risks associated with smoking and offers to support patient efforts to stop smoking. In particular, the appointment during which the diagnosis is communicated to the patient should be considered a 'teachable moment' that can lead to smoking cessation.

The clinical utility of contemporary oral epithelial dysplasia grading systems

INTRODUCTION

Clinical management of oral potentially malignant disorders relies on accurate histopathological assessment of the presence and grade of oral epithelial dysplasia. Whilst adjunctive laboratory tests have provided useful prognostic information, none are in widespread clinical use. This study was performed to assess the clinical utility of two contemporary oral epithelial dysplasia grading systems.

METHODS

Patients were identified from a clinical database. Oral epithelial dysplasia grading was performed by three oral and maxillofacial pathologists blinded to clinical outcome using the WHO 2017 system and a binary classification. The primary outcome measure was the development of oral squamous cell carcinoma, termed 'malignant transformation'.

RESULTS

131 cases satisfied the inclusion criteria, of which 23 underwent malignant transformation. There was substantial inter-rater agreement between the study pathologists for both grading systems, measured using kappa statistics (κ = 0.753-0.784). However, there was only moderate agreement between the consensus WHO 2017 dysplasia grade for the study against the original grade assigned by a pool of six pathologists in the context of the clinical service (κ = 0.491). Higher grade categories correlated with an increased risk of developing cancer using both grading systems.

CONCLUSION

This study demonstrates that the WHO 2017 and binary grading systems are reproducible between calibrated pathologists and that consensus reporting is likely to improve the consistency of grading. The WHO and binary systems were prognostically comparable. We recommend that institutions implement consensus oral epithelial dysplasia grading and prospectively audit the effectiveness of risk stratifying their patients with oral potentially malignant disorders. (249 words).

E-cigarette and cigarette use among cancer survivors versus general population: a case-control study in Korea

PURPOSE

Although successful smoking cessation after cancer diagnosis is important, research on e-cigarette use and smoking behavior among cancer survivors (CS) is limited. This study compared cigarette and e-cigarette use among CS and non-cancer populations in Korea.

METHODS

This study analyzed the 2013-2018 National Health and Nutrition Survey data to investigate e-cigarette use and smoking behavior among Korean CS. The data were categorized into 1260 CS and 5040 non-cancer populations using the propensity score matching method. A multiple logistic regression was conducted among CS who previously used cigarettes or e-cigarettes to evaluate factors influencing successful cessation.

RESULTS

Regarding conventional smoking, the proportion of ex-smokers was higher (25.2% versus 19.9%) than current smokers (6.7% versus 10.6%) in the CS group than in the propensity matched non-cancer population (PMNCP) (p < 0.001). However, ever use of e-cigarettes did not differ between them (2.4% versus 2.7%, p = 0.529). Successful cessation, defined as not using either cigarettes or e-cigarettes, correlated with problem drinking (OR 0.442, 95% CI 0.207-0.940), depression (OR 0.276, 95% CI 0.087-0.872), and cancer sites. CS of stomach, liver, colorectal, and lung cancer maintained higher successful smoking cessation rates than PMNCP.

CONCLUSIONS

Korean CS had a higher cessation rate than PMNCP regarding conventional smoking; however, there was no difference in e-cigarette use.

IMPLICATIONS FOR CANCER SURVIVORS

In Korea, some CS continue to use e-cigarettes, and physicians should focus on helping them quit. Individualized and timely interventions should be provided for both cigarette and e-cigarette users, considering factors influencing successful cessation.

Clinico-pathological study of malignant odontogenic tumours from a national referral centre

BACKGROUND

Malignant odontogenic tumours are extremely rare tumours occurring within the jaws. Our study was performed to determine the demographic and clinico-pathological features of malignant odontogenic tumours amongst a multi-ethnic Asian population.

METHODS

This was a retrospective cross-sectional study of malignant odontogenic tumours diagnosed at the Institute for Medical Research, Malaysia, from 2009 to 2019. All cases were independently reviewed and reclassified following the criteria set out in the latest edition of the World Health Organization 2017 reference text. Demographic and clinico-pathological data were recorded for each case.

RESULTS

Twenty-four cases of malignant odontogenic tumours were identified. The patients' age ranged from 16 to 79 years with the mean age at diagnosis being 50.8 years (SD = 16.18). There was a male predominance (66.7%) in this cohort of patients. The ethnic distribution appeared to reflect the Malaysian population with most cases seen amongst the Malay ethnic group (66.7%). Ameloblastic carcinoma was the most frequently diagnosed malignant odontogenic tumour (45.8%) and was also predominantly seen in males (90.9%). All patients with clear cell odontogenic carcinoma were females. There was no obvious sex predilection in primary odontogenic carcinoma not otherwise specified (NOS). The mandible (79.2%) was more frequently involved compared to the maxilla.

CONCLUSIONS

Diagnosis and management of malignant odontogenic tumours are challenging due to the rarity of these tumours. Our study has elucidated the clinico-pathological features of malignant odontogenic tumours seen in a multi-ethnic Asian population.

Dysplasia and DNA ploidy to prognosticate clinical outcome in oral potentially malignant disorders

BACKGROUND

Oral potentially malignant disorders are a clinical conundrum as there are no reliable methods to predict their behaviour. We combine conventional oral epithelial dysplasia grading with DNA ploidy analysis to examine the validity of this approach to risk assessment in a cohort of patients with known clinical outcomes.

METHODS

Sections from diagnostic biopsies were assessed for oral epithelial dysplasia using the WHO grading system, and DNA ploidy analysis was performed using established methods. Patients reviewed for a minimum of 5 years who did not develop oral squamous cell carcinoma were classified as "non-transforming" cases. Patients that developed oral squamous cell carcinoma ≥ 6 months after the initial diagnostic biopsy were classified as having "malignant transformation."

RESULTS

Ninety cases were included in the study. Seventy cases yielded informative DNA ploidy results. Of these 70 cases, 31 progressed to cancer. Oral epithelial dysplasia grading and DNA ploidy status were both significantly associated with clinical outcome (P < 0.05). Severe dysplasia had a hazard ratio of 3.50 (CI: 1.46, 8.45; P = 0.005) compared to cases with mild dysplasia. Aneuploidy had a hazard ratio of 2.09 (CI: 1.01, 4.32; P = 0.046) compared to cases with a diploid/tetraploid status. Receiver operating characteristic analysis gave an area under the curve of 0.617 for DNA ploidy status and 0.688 when DNA ploidy status was combined with dysplasia grading.

CONCLUSION

Our findings suggest that combining dysplasia grading with DNA ploidy status has clinical utility which could be used to develop novel management algorithms.

Validation of Self-Reported Smoking Status Among Orthopedic Hip Surgery Patients

Purpose

The purpose of this study was to determine the accuracy of self-reported non-smoking status in subjects undergoing elective orthopedic surgery as confirmed by serum cotinine levels.

Methods

Institutional Review Board approval was obtained for this retrospective review of consecutive subjects that underwent elective orthopedic surgery by a single fellowship-trained orthopedic surgeon. All patients provided smoking history (active, former, or non-smoker). Serum cotinine levels defined each subject as “non-smoker”, “passive tobacco exposure”, or “active smoker”. Self-reported non-smokers were eligible for inclusion. Subjects were excluded if they failed to provide smoking history, reported themselves as “smokers”, and/or had unavailable serum cotinine levels. Self-reported non-smoking status accuracy was determined by dividing the total number of included subjects by the number of subjects that were defined as “non-smoker” or “passive tobacco exposure” on their serum cotinine test.

Results

A total of 378 patients (mean age of 42.5 (13-78) years and 68% female) self-reported as non-smokers and were included. A total of 369 subjects had serum cotinine levels consistent with “non-smoking” resulting in a self-reported non-smoking status accuracy of 97.6%. None of the former smokers had cotinine levels consistent with active smoker status.

Conclusion

Subjects undergoing elective orthopedic surgery self-report as non-smokers with an accuracy of 97.6%. This suggests that routine serum cotinine testing of non-smokers in this patient population may not be necessary.

Effect of Smoking on Breast Cancer by Adjusting for Smoking Misclassification Bias and Confounders Using a Probabilistic Bias Analysis Method

Purpose

The aim of this study was to determine the association between smoking and breast cancer after adjusting for smoking misclassification bias and confounders.

Methods

In this case–control study, 1000 women with breast cancer and 1000 healthy controls were selected. Using a probabilistic bias analysis method, the association between smoking and breast cancer was adjusted for the bias resulting from misclassification of smoking secondary to self-reporting as well as a minimally sufficient adjustment set of confounders derived from a causal directed acyclic graph (cDAG). Population attributable fraction (PAF) for smoking was calculated using Miettinen’s formula.

Results

While the odds ratio (OR) from the conventional logistic regression model between smoking and breast cancer was 0.64 (95% CI: 0.36–1.13), the adjusted ORs from the probabilistic bias analysis were in the ranges of 2.63–2.69 and 1.73–2.83 for non-differential and differential misclassification, respectively. PAF ranges obtained were 1.36–1.72% and 0.62–2.01% using the non-differential bias analysis and differential bias analysis, respectively.

Conclusion

After misclassification correction for smoking, the non-significant negative-adjusted association between smoking and breast cancer changed to a significant positive-adjusted association.

Integration of Tobacco Treatment Services into Cancer Care at Stanford

As part of a National Cancer Institute Moonshot P30 Supplement, the Stanford Cancer Center piloted and integrated tobacco treatment into cancer care. This quality improvement (QI) project reports on the process from initial pilot to adoption within 14 clinics. The Head and Neck Oncology Clinic was engaged first in January 2019 as a pilot site given staff receptivity, elevated smoking prevalence, and a high tobacco screening rate (95%) yet low levels of tobacco cessation treatment referrals (<10%) and patient engagement (<1% of smokers treated). To improve referrals and engagement, system changes included an automated "opt-out" referral process and provision of tobacco cessation treatment as a covered benefit with flexible delivery options that included phone and telemedicine. Screening rates increased to 99%, referrals to 100%, 74% of patients were reached by counselors, and 33% of those reached engaged in treatment. Patient-reported abstinence from all tobacco products at 6-month follow-up is 20%. In July 2019, two additional oncology clinics were added. In December 2019, less than one year from initiating the QI pilot, with demonstrated feasibility, acceptability, and efficacy, the tobacco treatment services were integrated into 14 clinics at Stanford Cancer Center.

Electronic Cigarette Use among Survivors of Smoking-Related Cancers in the United States

BACKGROUND

The prevalence of electronic cigarette (e-cigarette) use and its impact on smoking cessation among cancer survivors in the United States is largely unknown. We sought to estimate the prevalence of e-cigarette use and examine its associations with cigarette smoking and smoking quit attempts among smoking-related cancer survivors in the United States.

METHODS

We obtained data from the 2014-2017 annual cycles of the National Health Interview Survey for participants with self-reported history of smoking-related cancer(s). We calculated the prevalence of current e-cigarette use and utilized multinomial logistic regression in examining the independent association between e-cigarette use and cigarette smoking. Appropriate survey weights were applied in estimating the prevalence rates, relative risk ratios (RRR), ORs, and confidence intervals (CI).

RESULTS

Our sample comprised 3,162 smoking-related cancer survivors. The prevalence of current e-cigarette use was 3.18% (95% CI, 2.40-3.96). Current e-cigarette users were 83 times as likely as never users to be current cigarette smokers (RRR, 82.89; 95% CI, 16.54-415.37). Among those with a history of cigarette smoking, current e-cigarette users were 90% less likely to be former smokers (OR, 0.10; 95% CI, 0.05-0.18). No association was seen between current e-cigarette use and a smoking quit attempt in the prior year.

CONCLUSIONS

E-cigarette use among cigarette ever smokers was associated with a lower likelihood of being a former smoker/having quit smoking, and e-cigarette use was not associated with smoking quit attempts.

IMPACT

Our findings do not provide evidence that e-cigarette use facilitates smoking cessation among smoking-related cancer survivors.

Smoking is associated with increased complications and readmission following extensor mechanism repair

PURPOSE

Extensor mechanism injuries are disabling injuries that require prompt evaluation and treatment and complications are often devastating. While smoking has been shown to increase complications following total joint arthroplasty, this relationship has not yet been established in those undergoing extensor mechanism repair. The purpose of this study was to evaluate the risk of smoking on postoperative complications following extensor mechanism repair.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients who underwent an extensor mechanism repair from 2005 to 2016. Patients were stratified by tobacco use, as either "current" or "nonsmokers." A multivariate logistic regression was used to control for demographic and comorbid factors while assessing perioperative complications.

RESULTS

5208 patients were identified, and of these, 843 (16.2%) were current smokers. Smokers were younger, male, and with lower BMIs compared to nonsmokers (p = 0.001, p = 0.003, p = 0.002, respectively). They had a higher rate of surgical complications (OR 1.61, CI 1.02-2.52), including deep surgical site infections (OR 3.27, CI 1.03-10.43) and unplanned return to the operating room (OR 2.001, 1.24-3.23). Smokers were more likely to be readmitted within 30 days of surgery (OR 1.78, OR 1.09-2.90).

CONCLUSION

Tobacco use is associated with a 1-2% increase in surgical, but not medical, complications following repair of extensor mechanism injuries. Smokers are at higher risk for deep infections, unplanned return to the OR, and hospital readmission. Identifying these patients preoperatively will allow surgeons to accurately counsel patients on perioperative risks. Counseling in preoperative smoking cessation is valuable for optimizing patient outcomes following extensor mechanism repair.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Oncologist provision of smoking cessation support: A national survey of Australian medical and radiation oncologists

AIM

Continued smoking in patients diagnosed with cancer affects treatment outcomes and overall survival. With national surveys of Australian medical oncologists (MO) and radiation oncologists (RO) we sought to determine current clinical practices, preferences and barriers in providing patient smoking cessation support.

METHODS

Oncologist members of the Medical Oncology Group of Australia (n = 452) and Trans-Tasman Radiation Oncology Group (n = 230) were invited to participate in a multiple choice survey exploring smoking cessation practices and beliefs.

RESULTS

The survey response rate was 43%. At first consultations more than 90% of MO and RO regularly asked patients if they smoke or use tobacco products, closely followed by documentation of duration of smoking history and current level of consumption. Less common was asking the patient if they intended to quit (MO 63%, RO 53%) and advising cessation (MO 70%, RO 72%). Less than 50% of oncologists regularly asked about current smoking in follow-up consultations. Although a range of referral options for smoking cessation care were used by oncologists, only 2% of MO and 3% of RO actively managed the patients' smoking cessation themselves and this was the least preferred option. The majority believed they require more training in cessation interventions (67% MO, 57% RO) and cited multiple additional barriers to providing cessation care.

CONCLUSIONS

Oncologists strongly prefer smoking cessation interventions to be managed by other health workers. A collaborative approach with other health professionals is needed to aid the provision of comprehensive smoking cessation care tailored to patients with cancer.

Active and Passive Smoking and Risk of Nasopharyngeal Carcinoma: A Population-Based Case-Control Study in Southern China

The magnitude and patterns of associations between smoking and risk of nasopharyngeal carcinoma (NPC) in high-incidence regions remain uncertain. Associations with active and passive tobacco smoking were estimated using multivariate logistic regression in a population-based case-control study of 2,530 NPC cases and 2,595 controls in Guangdong and Guangxi, southern China, in 2010-2014. Among men, risk of NPC was significantly higher in current smokers compared with never smokers (odds ratio (OR) = 1.32, 95% confidence interval (CI): 1.14, 1.53) but not in former smokers (OR = 0.92, 95% CI: 0.73, 1.17). Risk increased with smoking intensity (per 10 cigarettes/day, OR = 1.09, 95% CI: 1.03, 1.16), smoking duration (per 10 years, OR = 1.11, 95% CI: 1.06, 1.16), and cumulative smoking (per 10 pack-years, OR = 1.08, 95% CI: 1.04, 1.12). Risk decreased with later age at smoking initiation (per year, OR = 0.97, 95% CI: 0.96, 0.98) but not greater time since smoking cessation. Exposures to passive smoking during childhood (OR = 1.24, 95% CI: 1.03, 1.48) and from a spouse during adulthood (OR = 1.30, 95% CI: 1.03, 1.63) were independently associated with increased NPC risk in never-smoking men and women, but exposure-response trends were not observed. In conclusion, active and passive tobacco smoking are associated with modestly increased risk of NPC in southern China; risk is highest among long-term smokers.

The Effects of smoking status and smoking history on patients with brain metastases from lung cancer

There is limited data on the effects of smoking on lung cancer patients with brain metastases. This single institution retrospective study of patients with brain metastases from lung cancer who received stereotactic radiosurgery assessed whether smoking history is associated with overall survival, local control, rate of new brain metastases (brain metastasis velocity), and likelihood of neurologic death after brain metastases. Patients were stratified by adenocarcinoma versus nonadenocarcinoma histologies. Kaplan-Meier analysis was performed for survival endpoints. Competing risk analysis was performed for neurologic death analysis to account for risk of nonneurologic death. Separate linear regression and multivariate analyses were performed to estimate the brain metastasis velocity. Of 366 patients included in the analysis, the median age was 63, 54% were male and, 60% were diagnosed with adenocarcinoma. Current smoking was reported by 37% and 91% had a smoking history. Current smoking status and pack-year history of smoking had no effect on overall survival. There was a trend for an increased risk of neurologic death in nonadenocarcinoma patients who continued to smoke (14%, 35%, and 46% at 6/12/24 months) compared with patients who did not smoke (12%, 23%, and 30%, P = 0.053). Cumulative pack years smoking was associated with an increase in neurologic death for nonadenocarcinoma patients (HR = 1.01, CI: 1.00-1.02, P = 0.046). Increased pack-year history increased brain metastasis velocity in multivariate analysis for overall patients (P = 0.026). Current smokers with nonadenocarcinoma lung cancers had a trend toward greater neurologic death than nonsmokers. Cumulative pack years smoking is associated with a greater brain metastasis velocity.

Smoking Increases the Rate of Reoperation for Infection within 90 Days After Primary Total Joint Arthroplasty

BACKGROUND

The relationship between smoking and complications after total joint arthroplasty is unclear. Prior studies have been limited by relatively small sample sizes or investigation of select cohorts. The purpose of this study was to investigate the association between smoking and readmission and/or reoperation within 90 days of total joint arthroplasty in a large, non-select cohort of patients.

METHODS

Using our institutional database, we retrospectively identified patients who underwent primary total joint arthroplasty between 2000 and 2014. Patients were stratified into 1 of 3 groups: current smokers, former smokers, and nonsmokers. The association between smoking status and subsequent readmission and/or reoperation within 90 days was investigated using multivariate regression analysis.

RESULTS

We retrospectively identified 15,264 patients (6,749 male and 8,515 female) who underwent 17,394 total joint arthroplasties during the study period. Of these patients, 1,371 (9.0%) were current smokers, 5,195 (34.0%) were former smokers, and 8,698 (57.0%) were nonsmokers. Former smokers reported a median of 22.2 years (range, 0.2 to 60 years) of abstinence prior to the surgical procedure. Current smokers were significantly younger (p < 0.001) at a mean age (and standard deviation) of 57.7 ± 10.3 years than nonsmokers at 63.2 ± 11.8 years. Current smokers were significantly more likely than nonsmokers to undergo reoperation for infection (odds ratio [OR], 1.82 [95% confidence interval (CI), 1.03 to 3.23]; p = 0.04), and former smokers were at no increased risk (OR, 1.11 [95% CI, 0.73 to 1.69]; p = 0.61). Packs per decade were independently associated with an increased risk of 90-day nonoperative readmission regardless of smoking status (OR, 1.12 [95% CI, 1.03 to 1.20]). Lastly, neither smoking status nor packs per decade were associated with aseptic or total reoperations.

CONCLUSIONS

This study, after controlling for confounding factors, demonstrated not only that current smokers have a significantly increased risk of reoperation for infection within 90 days of a surgical procedure compared with nonsmokers, but also that the amount that one has smoked, regardless of current smoking status, significantly contributed to increased risk of nonoperative readmission.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Smoking status and symptom burden in surgical head and neck cancer patients

OBJECTIVES/HYPOTHESIS

Head and neck squamous cell carcinoma (HNSCC) patients who smoke are at risk for poor treatment outcomes. This study evaluated symptom burden and clinical, sociodemographic, and psychosocial factors associated with smoking in surgical patients to identify potential targets for supportive care services.

STUDY DESIGN

Cross-sectional survey.

METHODS

Individuals with HNSCC of the oral cavity, larynx, or pharynx were recruited from two cancer centers and completed questionnaires assessing smoking status (never, former, current/recent), patient characteristics, and symptoms before surgery.

RESULTS

Of the 103 patients enrolled, 73% were male, 52% were stage IV, 41% reported current/recent smoking, and 37% reported former smoking. Current/recent smokers were less likely than former smokers to have adequate finances (53% vs. 89%, P = .001) and be married/partnered (55% vs. 79%, P = .03). Current/recent smokers were also more likely than both former and never smokers to be unemployed (49% vs. 40% and 13%, respectively, all P = .02) and lack health insurance (17% vs. 5% and 13%, respectively, all P ≤.04). Fatalistic beliefs (P = .03) and lower religiosity (P =.04) were more common in current/recent than never smokers. In models adjusted for sociodemographic/clinical factors, current/recent smokers reported more problems than former and never smokers with swallowing, speech, and cough (P ≤.04). Current/recent smokers also reported more problems than never smokers with social contact, feeling ill, and weight loss (P ≤ .02).

CONCLUSIONS

HNSCC patients reporting current/recent smoking before surgery have high-risk clinical and sociodemographic features that may predispose them to poor postoperative outcomes. Unique symptoms in HNSCC smokers may be useful targets for patient-centered clinical monitoring and intervention.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:127-133, 2017.

Accuracy of Self-reported Smoking Exposure Among Bladder Cancer Patients Undergoing Surveillance at a Tertiary Referral Center

BACKGROUND

Smoking is a risk factor for developing bladder cancer (BCa). Even though continued exposure after diagnosis may adversely affect prognosis, patients may be reluctant to disclose to their physicians that they are currently smoking, leading to inaccurate reporting of exposure and missed opportunities to deliver smoking-cessation advice and treatment in the context of cancer care.

OBJECTIVE

We examined the extent of misclassification of recent smoking exposure among patients undergoing BCa surveillance.

DESIGN SETTING AND PARTICIPANTS

A consecutive sample of 145 patients with a self-reported smoking history and prior initial diagnosis of BCa was recruited from a tertiary referral urology clinic.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Patients were asked if they had smoked a cigarette or used nicotine replacement therapy (NRT) within the past week and whether they lived with a smoker. At the same visit, we collected urine under a biospecimen protocol. We used urinary cotinine, the primary metabolite of nicotine, as an objective biomarker of recent smoking exposure. Nine patients whose urine could not be interpreted for cotinine were excluded. We calculated the smoking status misreporting rate by comparing biochemically verified smoking status (≥31.5 ng/ml vs <31.5 ng/ml) against self-reported current smoking status (yes vs no) while considering recent NRT use.

RESULTS AND LIMITATIONS

Overall, 11% (15 of 136) of patients had cotinine values consistent with current smoking. Of these 15 patients, 7 reported being former smokers, resulting in a 47% misclassification rate. However, three of the seven patients who denied smoking in the past week were currently using NRT. Excluding NRT users, the misclassification rate was 33%.

CONCLUSIONS

Future studies investigating the impact of postdiagnosis nicotine exposure on BCa outcomes should use biochemical verification combined with self-reported smoking exposure to classify patients accurately.

PATIENT SUMMARY

Bladder cancer patients may misreport smoking exposure, thereby missing opportunities for smoking cessation.

Smoking cessation is associated with improved survival in oropharynx cancer treated by chemoradiation

OBJECTIVES/HYPOTHESIS

The effect of smoking and human papillomavirus (HPV) on overall survival (OS) of oropharyngeal squamous cell carcinoma (OPSCC) patients undergoing concurrent chemotherapy (CCRT) remains unclear.

STUDY DESIGN

Retrospective review.

METHODS

Clinical characteristics of OPSCC patients treated between 2008 and 2015 with CCRT were abstracted from medical records. OS curves and multivariate cox proportional hazard ratios (HRs) were examined.

RESULTS

Of 120 evaluable patients, 71% had HPV⁺ tumors. Median follow-up duration for the entire cohort was 41.5 months (range = 6-88 months). HPV⁺ current smokers experienced significantly worse 5-year OS (73% alive vs. 36% alive, P = .01) and there was a similar trend in HPV^- current smokers (66% alive vs. 31% alive, P = .28) compared to former/never smokers undergoing CCRT. In a multivariate cox proportional hazard model adjusted for age, gender, and overall tumor stage, HPV⁺ current smokers experienced nearly a fourfold increase in overall mortality in comparison to HPV⁺ never/former smokers (HR = 3.68, 95% CI = 1.35-10.0). Similarly, current smokers with HPV^- tumors (HR = 6.80, 95% CI = 1.11-41.67) had increased mortality compared to never/former smokers.

CONCLUSIONS

Current smoking is associated with poor prognosis, independent of HPV status, in CCRT-treated OPSCC patients. Current smoking produced an approximately four- to sevenfold increase in risk of mortality for HPV⁺ and HPV^- patients, respectively. Regardless of pack years and HPV status, efforts should be made to achieve smoking cessation before CCRT.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2733-2738, 2016.