The Effect of Mood, Anxiety, and Alcohol Use Disorders on Smoking Cessation in Cancer Patients

Examining the effects of stress and psychological distress on smoking abstinence in cancer patients

INTRODUCTION

Cancer patients who smoke report more stress and psychological distress than patients who do not smoke. It is unclear how these emotional symptoms may modify smoking behavior in cancer patients. We examined the influence of a smoking cessation intervention for cancer patients on stress and distress, and the effects of these symptoms on smoking abstinence.

METHODS

Mixed-methods secondary analysis of data from the Smokefree Support Study, a two-site randomized controlled trial examining the efficacy of Intensive (IT; n = 153) vs. Standard Treatment (ST; n = 150) for smoking cessation in newly diagnosed cancer patients. Stress coping, perceived stress, distress, and anxiety were self-reported at baseline, 3, and 6 months. Abstinence was biochemically-confirmed at 6 months. A subset of patients (n = 72) completed qualitative exit-interviews.

RESULTS

Patients were on average, 58 years old, 56% female, and smoked a median of 10 cigarettes/day. There were no significant treatment group × time interactions or main effects of treatment group on stress or distress measures (p's > 0.05), however there were significant main effects of time suggesting symptom improvements on each measure in both study groups (p's < 0.05). In adjusted logistic regression models, lower levels anxiety at 3 months predicted confirmed smoking abstinence at 6 months (p = .03). Qualitatively, at 6 months, patients reported their stress and smoking were connected and that the cessation counseling was helpful.

CONCLUSIONS

Cancer patients enrolled in a smoking cessation trial report decreases in stress, distress and anxiety over time, and anxiety symptoms may impact smoking cessation success at follow-up resulting in an important intervention target.

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

During a quit attempt, high negative affect predicts relapse to smoking. In this study, we evaluated bidirectional longitudinal associations between smoking and negative affect among cancer patients treated with varenicline. Participants (N = 119, 50% female, Mage = 59 years) were smokers (≥5 cigarettes/week) who were diagnosed with cancer and were recruited for a 24-week trial of extended duration varenicline plus behavioral counseling; data for this secondary analyses were drawn from the 12-week open-label phase of the trial. Smoking was assessed via self-reported number of cigarettes in the past 24 h. Negative affect was assessed using the Positive and Negative Affect Scale (PANAS). Data were collected at pre-quit (week 0), target quit day (week 1), week 4, and week 12. We evaluated cross-lagged panel models for negative affect and smoking using PROC CALIS in SAS. Models were run separately for participants who were adherent (≥80% of medication taken) or nonadherent to varenicline. Among adherent participants (n = 96), smoking accounted for up to 22% of variance in subsequent negative affect throughout treatment. Cross-lagged associations were not observed between smoking and negative affect among non-adherent participants (n = 23). Negative affect did not predict subsequent smoking among either adherent or nonadherent participants. These results suggest that varenicline may attenuate abstinence-induced negative affect among cancer patients treated for nicotine dependence.

Predictors of Smoking Cessation and Relapse in Cancer Patients and Effect on Psychological Variables: an 18-Month Observational Study

BACKGROUND

Although cancer patients are generally strongly advised to quit smoking in order to improve treatment efficacy and survival, up to 68 % of patients who were smokers at the time of cancer diagnosis continue smoking. Psychological factors such as depression and anxiety are likely to be associated with smoking behavior following a cancer diagnosis, but the empirical evidence is scarce.

PURPOSE

This observational study aimed at estimating smoking cessation rates and assessing the effect of smoking cessation on psychological symptoms, as well as the predictive role of the same psychological variables on smoking cessation and smoking relapse following cancer surgery.

METHODS

As part of a larger prospective, epidemiological study, smokers (n = 175) with a first diagnosis of nonmetastatic cancer completed the Hospital Anxiety and Depression Scale, the Insomnia Severity Index, and the Fear of Cancer Recurrence Inventory. Quitters (n = 55) and pair-matched nonquitters (n = 55) were compared on each symptom at pre-quitting, post-quitting, and at a 4-month follow-up. Predictors of smoking cessation and smoking relapse, including psychological variables, were also investigated.

RESULTS

Fifty-five patients (31.4 %) stopped smoking at least on one occasion during the study. Of the 55 quitters, 27 (49.1 %) experienced a relapse. At pre-quitting, quitters had significantly higher levels of anxiety (p = .03) and fear of cancer recurrence (p = .01) than nonquitters, symptoms that significantly diminished at post-quitting and 4 months later in this subgroup of patients. Having breast cancer significantly predicted smoking cessation (relative risk [RR] = 3.08), while depressive symptoms were a significant predictor of smoking relapse (RR = 1.07).

CONCLUSIONS

This study highlights the importance of psychological symptoms in predicting tobacco cessation and relapse among individuals with cancer. Our findings suggest that breast cancer patients are more inclined to stop smoking than patients with other cancers, but future studies should attempt to delineate the effect on smoking cessation of gender and other demographics that characterize this subgroup. This study also suggests that a particular attention should be paid to the early management of depressive symptoms in order to prevent smoking relapse.

Panic attacks and smoking cessation among cancer patients receiving smoking cessation treatment

OBJECTIVE

Little is known about factors associated with smoking cessation in cancer patients. This study examined the impact of panic attacks on smoking abstinence likelihood among cancer patients receiving tobacco cessation treatment.

METHOD

The relationship of panic attacks to 7-day point-prevalence abstinence at mid-treatment, end of treatment, and 6-month post-end of treatment were examined among cancer patients (N=2255 patients; 50.1% female; Mage=54.9, SD=11.0) who received counseling and pharmacotherapy for smoking cessation. Panic attack history indexed by two questions from the Patient Health Questionnaire (PHQ). Point-prevalence abstinence was assessed via the Timeline Follow-Back.

RESULTS

Cancer patients with a history of panic attacks, (n=493, 21.9%) relative to those without, were less likely to be abstinent at mid-treatment (OR=0.79, CI95%=0.64-0.98) and end of treatment (OR=0.72, CI95%=0.58-0.89). After adjusting for significant covariates, panic attack history remained predictive of decreased abstinence likelihood at end of treatment (OR =0.78, CI95%=0.62-0.99).

CONCLUSIONS

Panic attacks may be related to poorer cessation outcome during smoking treatment among cancer patients, and may be usefully assessed and targeted for intervention.

Impact of self-reported lifetime depression or anxiety on effectiveness of mass distribution of nicotine patches

BACKGROUND

Large-scale public health initiatives providing free nicotine replacement therapy have been shown to increase smoking cessation rates; however, their effectiveness among the highly prevalent population of smokers with depression and anxiety disorders has not been explored. The aim of this study was to investigate the influence of lifetime history of depression or anxiety on smoking cessation success following the free distribution of nicotine patches.

METHOD

In the context of a randomised controlled trial, a secondary analysis was conducted on 1000 adult regular smokers randomised to be mailed a 5-week supply of nicotine patches or to a no intervention control group. Participants were divided into subgroups based on the presence of self-reported lifetime diagnosis of depression and anxiety.

RESULTS

Irrespective of self-reported lifetime history of depression or anxiety, odds of self-reported cessation at 6 months were significantly greater among groups receiving nicotine patches compared to no intervention control (no history of depression or anxiety: OR 2.20; 95% CI 1.05 to 4.63; history of depression or anxiety present: OR 3.90; 95% CI 1.28 to 11.88). Among nicotine patch recipients only, quit outcomes did not differ between those with and without self-reported lifetime depression or anxiety in models unadjusted and adjusted for differences in demographic and smoking characteristics.

CONCLUSIONS

The mass distribution of free nicotine patches (without behavioural support) is effective among smokers with or without lifetime history of depression or anxiety alike, providing further support for the adoption of similar initiatives as a means of promoting tobacco cessation on a population level.

TRIAL REGISTRATION NUMBER

NCT01429129, Post-results.

Helping patients to reduce tobacco consumption in oncology: a narrative review

The present overview focuses on evidence of smoking cessation approaches in oncology settings with the aim to provide health personnel a critical perspective on how to help their patients. This narrative review is structured in two main sections: the first one describes the psycho-cognitive variables involved in the decision to continue smoking after a cancer diagnosis and during the treatment; the second section relates methods and tools may be recommended, being evidence-based, to support smoking cessation in oncology settings. Active smoking increases not only susceptibility to common cancers in the general population, but also increases disease severity and comorbidities in cancer patients. Nowadays, scientific evidence has identified many strategies to give up smoking, but a lack of knowledge exists for treatment of nicotine dependence in the cancer population. Health personnel is often ambiguous when approaching the problem, while their contribution is essential in guiding patients towards healthier choices. We argue that smoking treatments for cancer patients deserve more attention and that clinical features, individual characteristics and needs of the patient should be assessed in order to increase the attempts success rate. Health personnel that daily work and interact with cancer patients and their caregivers have a fundamental role in the promotion of the health changing. For this reason, it is important that they have adequate knowledge and resources in order to support cancer patients to stop tobacco cigarette smoking and promoting and healthier lifestyle.

Smoking cessation treatment and outcomes in medium to heavy cigarette smokers being treated for cancer in Jordan

BACKGROUND

Studies evaluating smoking cessation treatment outcomes in cancer patients are scarce, despite smoking cessation importance in cancer care. We sought to add to the literature by evaluating smoking cessation in a challenging group of cancer patients (medium-to-heavy smokers) visiting an out-patient smoking cessation clinic (SCC) in a cancer center in Amman, Jordan.

MATERIALS AND METHODS

Patients smoking >9 cigarettes per day (CPD) and referred to the SCC between June 2009 and May 2012 were studied. Clinic records were reviewed to measure demographic and baseline clinical characteristics, and longitudinal (3-, 6- and 12- month) follow- up by phone/clinic visit was conducted. At each follow-up, patients were asked if they experienced medication side-effects, if they had returned to smoking, and reasons for failing to abstain. Descriptive and multivariable logistic regression analyses were performed.

RESULTS

A total of 201 smokers were included in the analysis. The 3-month abstinence was 23.4% and significantly associated with older age, being married, and presenting with lower (≤ 10 ppm) baseline carbon monoxide (CO) levels. On a multivariable level, lower CO levels, a higher income (relative to the lowest income group), being older, and reporting severe dependence (relative to dependence reported as 'somewhat' or 'not') were significant predictors of higher odds of abstinence at three months. Reasons for failing to quit included not being able to handle withdrawal and seeing no value in quitting. Long- term ARs did not reach 7%.

CONCLUSIONS

In a sample of Jordanian smokers (>9CPD) with cancer and receiving smoking cessation treatment, ARs were low and further declined with time. Results underscore the need for more aggressive patient management and rigorous follow-up during and after smoking cessation treatment, particularly when this takes place in challenging settings. Observed reasons for failure to abstain should be used to tailor counseling practices.

Tobacco use and cessation for cancer survivors: an overview for clinicians

Approximately 30% of all cancer deaths in the United States are caused by tobacco use and smoking. Cancers of eighteen sites have been causally linked to smoking, the most common of which are the lung, head and neck, bladder, and esophagus. While quit rates and quit attempt rates are relatively high shortly after a cancer diagnosis, the recidivism rates are also high. Therefore, screening, treating, and preventing relapse to tobacco use is imperative among patients with and survivors of cancer. To date, research has consistently shown that a combination of pharmacologic and behavioral interventions is needed to achieve the highest smoking cessation rates, with a recent emphasis on individualized treatment as a most promising approach. Challenges in health care systems, including the lack of appropriate resources and provider training, have slowed the progress in addition to important clinical considerations relevant to the treatment of tobacco dependence (eg, a high degree of comorbidity with psychiatric disorders and other substance use disorders). However, continued tobacco use has been shown to limit the effectiveness of major cancer treatments and to increase the risk of complications and of developing secondary cancers. The authors recommend that oncology providers screen all patients for tobacco use and refer users to specialized treatment when available. Alternatively, oncology clinicians can provide basic advice on tobacco use cessation and pharmacotherapy and/or referral to outside resources (eg, quitlines). Herein, the authors summarize the current knowledge on tobacco use and its treatment, with a focus on the related available evidence for patients with and survivors of cancer.

Smoking cessation interventions for smokers with current or past depression

BACKGROUND

Individuals with current or past depression are often smokers who are more nicotine dependent, more likely to suffer from negative mood changes after nicotine withdrawal, and more likely to relapse to smoking after quitting than the general population, which contributes to their higher morbidity and mortality from smoking-related illnesses. It remains unclear what interventions can help them to quit smoking.

OBJECTIVES

To evaluate the effectiveness of smoking cessation interventions, with and without specific mood management components, in smokers with current or past depression.

SEARCH METHODS

In April 2013, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, other reviews, and asked experts for information on trials.

SELECTION CRITERIA

Criteria for including studies in this review were that they had to be randomised controlled trials (RCTs) comparing smoking cessation interventions in adult smokers with current or past depression. Depression was defined as major depression or depressive symptoms. We included studies where subgroups of participants with depression were identified, either pre-stated or post hoc. The outcome was abstinence from smoking after six months or longer follow-up. We preferred prolonged or continuous abstinence and biochemically validated abstinence where available.

DATA COLLECTION AND ANALYSIS

When possible, we estimated pooled risk ratios (RRs) with the Mantel-Haenszel method (fixed-effect model). We also performed subgroup analyses, by length of follow-up, depression measurement, depression group in study, antidepressant use, published or unpublished data, format of intervention, level of behavioural support, additional pharmacotherapy, type of antidepressant medication, and additional nicotine replacement therapy (NRT).

MAIN RESULTS

Forty-nine RCTs were included of which 33 trials investigated smoking cessation interventions with specific mood management components for depression. In smokers with current depression, meta-analysis showed a significant positive effect for adding psychosocial mood management to a standard smoking cessation intervention when compared with standard smoking cessation intervention alone (11 trials, N = 1844, RR 1.47, 95% CI 1.13 to 1.92). In smokers with past depression we found a similar effect (13 trials, N = 1496, RR 1.41, 95% CI 1.13 to 1.77). Meta-analysis resulted in a positive effect, although not significant, for adding bupropion compared with placebo in smokers with current depression (5 trials, N = 410, RR 1.37, 95% CI 0.83 to 2.27). There were not enough trial data to evaluate the effectiveness of fluoxetine and paroxetine for smokers with current depression. Bupropion (4 trials, N = 404, RR 2.04, 95% CI 1.31 to 3.18) might significantly increase long-term cessation among smokers with past depression when compared with placebo, but the evidence for bupropion is relatively weak due to the small number of studies and the post hoc subgroups for all the studies. There were not enough trial data to evaluate the effectiveness of fluoxetine, nortriptyline, paroxetine, selegiline, and sertraline in smokers with past depression.Twenty-three of the 49 trials investigated smoking cessation interventions without specific components for depression. There was heterogeneity between the trials which compared psychosocial interventions with standard smoking cessation counselling for both smokers with current and past depression. Therefore, we did not estimate a pooled effect. One trial compared nicotine replacement therapy (NRT) versus placebo in smokers with current depression and found a positive, although not significant, effect (N = 196, RR 2.64, 95% CI 0.93 to 7.45). Meta-analysis also found a positive, although not significant, effect for NRT versus placebo in smokers with past depression (3 trials, N = 432, RR 1.17, 95% CI 0.85 to 1.60). Three trials compared other pharmacotherapy versus placebo and six trials compared other interventions in smokers with current or past depression. Due to heterogeneity between the interventions of the included trials we did not estimate pooled effects.

AUTHORS' CONCLUSIONS

Evidence suggests that adding a psychosocial mood management component to a standard smoking cessation intervention increases long-term cessation rates in smokers with both current and past depression when compared with the standard intervention alone. Pooled results from four trials suggest that use of bupropion may increase long-term cessation in smokers with past depression. There was no evidence found for the use of bupropion in smokers with current depression. There was not enough evidence to evaluate the effectiveness of the other antidepressants in smokers with current or past depression. There was also not enough evidence to evaluate the group of trials that investigated interventions without specific mood management components for depression, including NRT and psychosocial interventions.

Long-term outcomes of a cell phone-delivered intervention for smokers living with HIV/AIDS

BACKGROUND

People living with human immunodeficiency virus (HIV)/AIDS (PLWHA) have a substantially higher prevalence of cigarette smoking compared to the general population. In addition, PLWHA are particularly susceptible to the adverse health effects of smoking. Our primary objective was to design and test the efficacy over 12 months of a smoking cessation intervention targeting PLWHA.

METHODS

Participants were enrolled from an urban HIV clinic with a multiethnic and economically disadvantaged patient population. Participants received smoking cessation treatment either through usual care (UC) or counseling delivered by a cell phone intervention (CPI). The 7-day point prevalence abstinence was evaluated at 3, 6, and 12 months using logistic regression and generalized linear mixed models.

RESULTS

We randomized 474 HIV-positive smokers to either the UC or CPI group. When evaluating the overall treatment effect (7-day abstinence outcomes from 3-, 6-, and 12-month follow-ups), participants in the CPI group were 2.41 times (P = .049) more likely to demonstrate abstinence compared to the UC group. The treatment effect was strongest at the 3-month follow-up (odds ratio = 4.3, P < .001), but diminished at 6 and 12 months (P > .05).

CONCLUSIONS

Cell phone-delivered smoking cessation treatment has a positive impact on abstinence rates compared to a usual care approach. Future research should focus on strategies for sustaining the treatment effect in the long term.

Smoking cessation, depression, and exercise: empirical evidence, clinical needs, and mechanisms

INTRODUCTION

Smoking is significantly more common among persons with major depressive disorders (MDDs). Furthermore, smokers with MDD report more difficulties when they quit smoking (greater withdrawal symptoms, higher probability of relapse). The aim of this narrative review is to describe research on exercise and depression and exercise and smoking cessation.

METHODS

We have critically reviewed various smoking cessation intervention programs for depressive smokers examining (a) the protective effect of exercise against relapse for smokers with MDD and (b) the benefits of exercise for treating withdrawal symptoms. We have also reviewed the current literature investigating the mechanisms between exercise-depression and exercise-smoking.

RESULTS

This review suggests that exercise may reduce depressive symptoms following cessation and provide a useful strategy for managing withdrawal symptoms in smokers with MDD. Various psychological, biological, and genetic hypotheses have been tested (e.g., distraction hypothesis, expectations hypothesis, cortisol hypothesis) and few have obtained significant results.

CONCLUSIONS

It might be beneficial for health professionals to recommend physical activity and promote supervised exercise sessions for smokers with MDD during smoking cessation. Future research needs to examine relationships between exercise, smoking, and depression with transdisciplinary and ecological momentary assessment.

Survivors at higher risk for adverse late outcomes due to psychosocial and behavioral risk factors

Cancer survivors face significant morbidity and mortality associated with their disease and treatment regimens, some of which can be improved through modifying behavioral and psychosocial risk factors. This article examines risk factors for adverse late effects that contribute to morbidity and mortality in cancer survivors, provides a literature review on interventions to modify these risks factors, and summarizes the national recommendations and associated current practices for identifying and managing these risk factors. Finally, future directions for research and clinical practice are discussed.