Tobacco use among pediatric cancer patients: recommendations for developing clinical smoking interventions

Health Behaviors of Childhood Cancer Survivors

There has been a dramatic increase in the number of childhood cancer survivors living to an old age due to improved cancer treatments. However, these survivors are at risk of numerous late effects as a result of their cancer therapy. Engaging in protective health behaviors and limiting health damaging behaviors are vitally important for these survivors given their increased risks. We reviewed the literature on childhood cancer survivors’ health behaviors by searching for published data and conference proceedings. We examine the prevalence of a variety of health behaviors among childhood cancer survivors, identify significant risk factors, and describe health behavior interventions for survivors.

Correlates of continued smoking versus cessation among survivors of smoking-related cancers

OBJECTIVE

We examined correlates of continued smoking versus cessation among a sample of survivors of smoking-related cancers who were actively smoking at the time of cancer diagnosis.

METHODS

Participants with a history of smoking and a smoking-related cancer diagnosis (lung, oral, pharynx, larynx, esophagus, bladder, stomach, cervix, kidney, pancreas, acute myeloid leukemia) within the past 4 years were identified in the electronic medical record. We recruited 613 individuals to complete a mail-based survey and received 139 completed surveys (22.7% response rate). We focused on 105 participants who smoked at the time of diagnosis and dichotomized them to having either quit since diagnosis (48.6%; n = 51) or continued smoking (51.4%; n = 54). We assessed sociodemographics, type of cancer and treatment(s), and psychosocial factors (depressive symptoms, social support, hope, quality of life). We then conducted structured interviews with a subset of 21 survey respondents.

RESULTS

Binary logistic regression indicated that, controlling for age, gender, ethnicity, marital status, and income, factors associated with continued smoking versus cessation included being diagnosed with other smoking-related cancers versus lung or head and neck cancer (OR = 11.21, CI 2.85, 44.02) and having significant depressive symptoms (OR = 1.25, CI 1.08, 1.45). Qualitative findings highlighted motivators for cessation (impact of being diagnosed with cancer, doctor advice to quit, social influences) and barriers to cessation (hopelessness, stress, addiction).

CONCLUSIONS

These findings highlight the need to address depressive symptoms among cancer survivors, particularly those continuing to smoke and the importance of exploring messages cancer survivors are given regarding the need for cessation post cancer diagnosis.

Harm reduction and cessation efforts and interest in cessation resources among survivors of smoking-related cancers

PURPOSE

Despite the well-established risks associated with persistent smoking, many cancer survivors who were active smokers at the time of cancer diagnosis continue to smoke. In order to guide the development of tobacco cessation interventions for cancer survivors, a better understanding is needed regarding post-diagnosis quitting efforts. Thus, we examined quitting and reduction efforts and interest in cessation resources among cancer survivors who self-identified as current smokers at the time of diagnosis.

METHODS

We conducted analyses of survey participants (n = 54) who were current smokers at the time of cancer diagnosis and were continued smokers at the time of assessment. We also conducted semi-structured interviews (n = 21) among a subset of those who either continued to smoke or quit smoking post-cancer diagnosis.

RESULTS

Among our survey participants, 22.2 % had ever used behavioral cessation resources and 66.7 % had use pharmacotherapy, while 62.8 % had interest in future use of behavioral cessation resources and 75.0 % had interest in pharmacotherapy. The majority reported some quitting efforts including making quit attempts, using cessation medications, and reducing their daily cigarette consumption. Semi-structured interview data revealed various strategies used to aid in smoking reduction and cessation as well as variability in preferences for cessation resources.

CONCLUSIONS

Cancer patients who smoke following diagnosis often engage in smoking reduction and cessation-related behaviors, which may reflect their motivation to reduce their smoking-related risks. They also report high interest in cessation resources. Thus, it is important to explore the acceptability and effectiveness of different cessation intervention components among this group.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors who smoke demonstrate actions toward harm reduction and cessation. They should inquire about potential resources that might facilitate their efforts among their healthcare providers and enlist support and advice from others around them to bolster their efforts.

Cancer survivorship research: a review of the literature and summary of current NCI-designated cancer center projects

The number of cancer survivors and the amount of cancer survivorship research have grown substantially during the past three decades. This article provides a review of interventional and observational cancer survivorship research efforts as well as a summary of current cancer survivorship research projects being conducted by National Cancer Institute-designated cancer centers in an effort to identify areas that need further attention.

Anti-Smoking Communication to Preadolescents with and without a Cancer Diagnosis: Parents and Healthcare Providers as Important Communicators

A cancer diagnosis does not prevent smoking among pediatric oncology patients, and anti-smoking communications among parents and health care providers have been proposed as influencing smoking outcomes in this group. Anti-smoking communications were compared among 93 preadolescents with cancer and 402 controls. After adjusting for demographics and covariates, preadolescents with cancer were less likely than control participants to report receipt of anti-smoking messages from physicians and parents, and recalled more messages >/= 4 months post-diagnosis as compared to 1-3 months. Should anti-tobacco communications prove to influence smoking outcomes, parents and physicians may be uniquely positioned to provide smoking prevention interventions to these patients.

Smoking and binge drinking among Canadian survivors of childhood and adolescent cancers: a comparative, population-based study

BACKGROUND

Objectives of this study were to describe the prevalence of smoking and binge drinking among survivors of childhood and adolescent cancer compared to controls who had never had cancer, and to identify factors associated with these behaviors.

PROCEDURE

Data came from a national, multi-centre, population-based study of survivors of childhood and adolescent cancer (n = 1,263) aged 16 to 37 years and an age and gender matched control group (n = 1,422). Logistic regression analyses were performed to determine the likelihood and predictors of current smoking and binge drinking.

RESULTS

Survivors were less likely to be current smokers (OR(adj) = 0.65, 95% CI = 0.54-0.77) and binge drinkers (OR(adj) = 0.66, 95% CI = 0.55-0.78) than the controls. Still, a substantial proportion of survivors reported smoking (23%) and binge drinking (25%). Survivors' smoking and binge drinking did not vary substantially by the clinical factors assessed. Survivors who received therapy associated with cardiac and/or pulmonary toxicity were as likely to smoke as non-exposed survivors. For both the survivors and controls current smoking and binge drinking were associated with lower education and higher reported stress. Binge drinking was also associated with being male and life dissatisfaction in both groups.

CONCLUSIONS

This study indicates a need to reduce smoking and binge drinking among survivors of childhood and adolescent cancer and to design interventions addressing the underlying reasons for adopting unhealthy behaviors despite their risk for late effects. We identified factors related to smoking and binge drinking among survivors: being male, lower educational attainment, life dissatisfaction and high stress, which should help inform intervention development.

Health behaviours in childhood cancer survivors: a systematic review

AIM

To review (1) prevalence and predictors of risk behaviours especially smoking and (2) values of interventions to reduce risk behaviours in childhood cancer survivors.

METHOD

A systematic search of four databases (OVID Medline (1966 to May week 2, 2006), CINAHL, EMBASE, and Pubmed (US Library of Medicine and National Institute of Health)) for articles published between January 1990 and May 2006.

RESULTS

Twenty-three eligible articles. Incidence of risk behaviours are comparable with, or lower than the general population and controls. Socio-demographic (age, socio-economic status, diagnosis, ethnic group) and psychological variables (perceived vulnerability) predict risk behaviour. Improved knowledge and awareness of vulnerability have been found after interventions, but no changes in health behaviours.

CONCLUSION

This review illustrates an optimistic picture of low participation in substance use amongst survivors, although based mainly on smoking. However, smoking might not be the major problem for survivors and attention must also be directed to other health behaviours including exercise and healthy diet.

Smoking rates and the state of smoking interventions for children and adolescents with chronic illness

Engaging in smoking is particularly risky for children and adolescents with chronic illness whose health status is already compromised because of disease- and treatment-related complications. Yet, some of these youngsters smoke at rates at least comparable to those of their healthy peers. To date, few randomized smoking-prevention and cessation trials have been conducted in children with chronic medical problems. In this review we report on the smoking rates among youngsters with chronic illness, identify specific disease- and treatment-related complications that can be exacerbated by smoking, examine risk factors associated with tobacco use among medically compromised youngsters, and review smoking interventions that have been conducted to date with pediatric populations in the health care setting. The following chronic illnesses are included in this review: asthma, cystic fibrosis, cancer, sickle cell disease, juvenile-onset diabetes, and juvenile rheumatoid arthritis. Objectives for a tobacco-control agenda and recommendations for future tobacco studies in chronically ill pediatric populations are provided. Finally, tobacco counseling strategies are suggested for clinicians who treat these youngsters in their practices.

Health behaviors during and after a cancer diagnosis

With improvements in cancer survival rates, more patients with cancer are living longer, and hence, cancer is becoming viewed as a chronic illness requiring long-term management. An important aspect of patient care during and after cancer treatment is patient health behaviors. For example, sequelae from various cancer treatments, such as chemotherapy and radiotherapy (RT), can compromise health in a variety ways, including decreased immune functioning, cardiotoxic effects of chemotherapy and/or RT, and weight gain. In addition, the stress caused by a cancer diagnosis and its treatment can disrupt existing health behaviors or exacerbate unhealthy behaviors. Continued smoking or alcohol use can complicate treatment and increase risk for further malignancy. Furthermore, decreased physical activity and poor nutrition can cause weight gain, which may contribute to secondary health problems such as cardiovascular disease and diabetes. The authors reviewed the extant literature on four key health behaviors among patients with cancer and survivors: healthy diet, reduced tobacco use, reduced alcohol use, and increased physical activity. They described the prevalence of these behaviors, reviewed the effects of interventions designed to alter unhealthy behaviors, and discussed the implications and future directions for this emerging area of research.

Sex, drugs and chronic illness: health behaviours among chronically ill youth

BACKGROUND

A growing body of literature indicates that adolescents with chronic conditions are as likely, or more likely, to take risky behaviours than their healthy peers. The objective of this research was to assess whether adolescents with chronic illness in Catalonia differ from their healthy peers in risk-taking behaviour.

METHODS

Data were drawn from the Catalonia Adolescent Health database, a survey including a random school-based sample of 6952 young people, aged 14-19 years. The index group (IG) included 665 adolescents (450 females) reporting several chronic conditions. The comparison group (CG) comprised 6287 healthy adolescents (3306 females). Personal, family and school-related variables were analysed to ensure comparability between groups. Sexual behaviour, drug use (tobacco, alcohol, cannabis, cocaine and synthetic drugs) and perception of drug use among peers and in school were compared. Analysis was carried out separately by gender. chi-square, Fisher's and Student's tests were used to compare categorical and continuous variables.

RESULTS

The prevalence of chronic conditions was 9.6%, with females showing a higher prevalence than males. The IG showed similar or higher rates of sexual intercourse and risky sexual behaviour. For most studied drugs, IG males reported slightly lower rates of use than CG males, while IG females showed higher rates for every drug studied. No differences were found in the perceptions of drug use among peers or in their school.

CONCLUSIONS

Similar to previous research, chronically ill adolescents in our sample are as likely, or more likely, to take risky behaviours than their healthy counterparts and should receive the same anticipatory guidance.

Predictors of smoking initiation and cessation among childhood cancer survivors: a report from the childhood cancer survivor study

PURPOSE

To examine the determinants of smoking behavior among participants in the Childhood Cancer Survivors Study (CCSS).

METHODS

This retrospective cohort survey study was conducted among 9,709 childhood cancer survivors. Main outcomes included smoking initiation and cessation.

RESULTS

Twenty-eight percent of patients reported ever smoking and 17% reported being current smokers. Standardized to United States population rates, the observed to expected (O/E) ratios and corresponding 95% confidence limits (95% CL) of cigarette smoking were 0.72 (95% CL, 0.69, 0.75) among all survivors and 0.71 (95% CL, 0.68 to 0.74) and 0.81 (95% CL, 0.70, 0.93) among whites and nonwhites, respectively. Significantly lower O/E ratios were present among both males (O/E, 0.73) and females (O/E, 0.70). Factors independently associated with a statistically significant relative risk of smoking initiation included older age at cancer diagnosis, lower household income, less education, not having had pulmonary-related cancer treatment, and not having had brain radiation. Blacks were less likely to start smoking. Survivors who smoked were significantly more likely to quit (O/E, 1.22; 95% CL, 1.15, 1.30). Among ever-smokers, factors associated with the likelihood of being a current smoker included age less than 13 years at smoking initiation, less education, and having had brain radiation; those age less than 3 years at cancer diagnosis were significantly more likely to be ex-smokers.

CONCLUSIONS

Although survivors in the CCSS cohort seem to be smoking at rates below the general population, interventions are needed to prevent smoking initiation and promote cessation in this distinct population.

Predictors of tobacco control among nursing students

As the most numerous health care providers, nurses could reduce tobacco-related morbidity and mortality. A cross-sectional survey of 476 junior and senior students at 12 schools of nursing in the New York metropolitan area was conducted, to determine nurse knowledge of tobacco control, their attitudes, beliefs, and practices. Overall, 76% of all nursing students reported that they practiced tobacco control. Current smokers were less likely to participate in tobacco control with targets ranging from the nurse herself to the community than either never or ex-smokers. Nurses were more likely to engage in tobacco control among individual, family, or group clients than to advocate for changes in the community. Student nurses who were African American or Hispanic, had never smoked or were ex-smokers, those who had better knowledge of cessation approaches, and those who tended to have more confidence in their cessation counseling skills were more likely to engage in multi-target tobacco control than other similar nurses. Tailored interventions that emphasize discrete counseling skills are suggested.

Health behavior changes after a cancer diagnosis: what do we know and where do we go from here?

Survival rates for certain types of cancer have improved over the past few decades. Changing unhealthy behaviors such as smoking, poor diet, and sedentary life-style among individuals who have been diagnosed with cancer may help to reduce cancer treatment sequelae, possibly reduce risk of recurrence for specific types of cancer, and reduce risk for other common diseases such as cardiovascular disease, obesity, and hypertension. This article reports the prevalence of each of these behaviors among those diagnosed with cancer and reviews interventions that have targeted these risk behaviors. There is considerable variation in the type of research questions asked, the methodologic quality of the research, sample sizes, and the outcomes observed across studies focusing on changing the three health risk behaviors. In the final section, we provide guidelines for researchers in developing health behavior interventions for individuals diagnosed with cancer and highlight challenges that should be addressed.

Aggression, antisocial behavior, and substance abuse in survivors of pediatric cancer: possible protective effects of cancer and its treatment

OBJECTIVE

To examine aggression, antisocial behavior, and substance abuse in young adult survivors of pediatric cancer (PCS) relative to case control peers (CC).

METHODS

We obtained self-reports of current aggression, antisocial behavior, and lifetime substance use from 26 PCS (time off-treatment, M: = 56 months) and 26 CC using the Antisocial Behavior Checklist and the Drinking and Drug History. A report of current aggression and antisocial behavior also was obtained from primary caregivers using the Child Behavior Checklist.

RESULTS

PCS self-reported significantly less illegal drug use and experimentation than CC. No significant differences emerged between groups for use of alcohol and tobacco nor for aggression and antisocial behavior.

CONCLUSIONS

PCS are functioning as well as, or better than, CC in terms of aggression, antisocial behavior, and substance abuse. However, given the compromised health status of survivors, efforts should focus on further reduction of drug-related risk behaviors that may amplify organ damage or increase risk for further malignancies in this population.

Late effects of treatment in survivors of childhood acute myeloid leukemia

PURPOSE

To investigate the incidence of and risk factors for late sequelae of treatment in patients who survived for more than 10 years after the diagnosis of childhood acute myeloid leukemia (AML).

PATIENTS AND METHODS

Of 77 survivors (median follow-up duration, 16. 7 years), 44 (group A) had received chemotherapy, 18 (group B) had received chemotherapy and cranial irradiation, and 15 (group C) had received chemotherapy, total-body irradiation, and allogeneic bone marrow transplantation. Late complications, tobacco use, and health insurance status were assessed.

RESULTS

Growth abnormalities were found in 51% of survivors, neurocognitive abnormalities in 30%, transfusion-acquired hepatitis in 28%, endocrine abnormalities in 16%, cataracts in 12%, and cardiac abnormalities in 8%. Younger age at the time of diagnosis or initiation of radiation therapy, higher dose of radiation, and treatment in groups B and C were risk factors for the development of academic difficulties and greater decrease in height Z: score. In addition, treatment in group C was a risk factor for a greater decrease in weight Z: score and the development of growth-hormone deficiency, hypothyroidism, hypogonadism, infertility, and cataracts. The estimated cumulative risk of a second malignancy at 20 years after diagnosis was 1.8% (95% confidence interval, 0.3% to 11.8%). Twenty-two patients (29%) were smokers, and 11 (14%) had no medical insurance at the time of last follow-up.

CONCLUSION

Late sequelae are common in long-term survivors of childhood AML. Our findings should be useful in defining areas for surveillance of and intervention for late sequelae and in assessing the risk of individual late effects on the basis of age and history of treatment.

Smoking in adult survivors of childhood acute lymphoblastic leukemia

BACKGROUND

Health-related behaviors are of particular concern in survivors of childhood cancer as they are at increased risk for second cancers and long-term organ dysfunction. The purpose of this study was to compare the smoking behavior and associated factors in young-adult survivors of childhood acute lymphoblastic leukemia (ALL) with those in sibling controls.

METHODS

A telephone interview that surveyed smoking behavior was conducted with 592 young-adult survivors, treated before age 20 years on Children's Cancer Group ALL protocols, and 409 sibling controls. Using stratified chi-squared analyses and Cox proportional hazards models, we compared the rates of smoking initiation and smoking cessation between survivors and control subjects. Demographic characteristics (age, sex, race, and education) and psychological factors (mood and self-concept) were examined as predictors interacting with survivorship in logistic regression analyses to try to distinguish a subgroup of survivors who may be at greater risk for smoking.

RESULTS

Survivors were significantly less likely to have ever smoked (23.0% versus 35.7%; P<.0001) and thus were less likely to ever be regular, daily smokers than sibling controls (19.1% versus 31.3%; P<.0001). Survivors were less likely to quit smoking than sibling controls (26.6% versus 35.2%), although this result was not statistically significant. There were no interactions between survivor status and either demographic or psychological features on smoking behavior.

CONCLUSIONS

Young-adult survivors of childhood ALL are less likely to experiment with smoking but, once having started, are at similar risk for becoming habitual, persistent smokers as sibling controls.