Smoking Addiction High Even After HNSCC Dx, Tx

Cigarette addiction is real, a truth that may be especially evident after a cancer diagnosis, according to results from a prospective cohort study of patients with head and neck squamous cell carcinoma (HNSCC). This study found that most of those who smoke at the time of cancer diagnosis continue to do so during and after treatment. However, there may be a window of opportunity for clinicians to help patients quit after treatment.

Tyler Van Heest, MD, MA, from the Department of Otolaryngology–Head and Neck Surgery, University of Minnesota, Minneapolis, and colleagues found that 58.4% of patients with HNSCC continued to smoke 6 months after treatment, and 62.5% of those still living 2 years later were still smoking.

Still, the small bright spot for getting patients to quit and remain tobacco-free was in the first 6 months after treatment, Van Heest and colleagues noted in JAMA Otolaryngology-Head and Neck Surgery.

"The probability of successful smoking cessation between diagnosis and 6 months after treatment was 0.36, which was approximately 3 times higher than the probability of successful smoking cessation during any other time interval," the study authors wrote. "Patients who continued to smoke at 6 months after treatment were highly likely to still be smoking at 24 months after treatment, and patients who successfully quit smoking by 6 months after treatment were likely to continue to abstain from tobacco use at 24 months after treatment. In fact, the probability of remaining abstinent rose with each time interval. Therefore, the time between diagnosis and the first 6 months after treatment appears to be a crucial time for health care practitioners to proactively address tobacco cessation."

In a 2019 review article published in Translational Lung Cancer Research, Jacek Jassem, MD, PhD, Department of Oncology and Radiotherapy, Medical University of Gdansk, Poland, wrote: "The diagnosis of cancer is ’the teachable moment’, allowing health care professionals the best opportunity to discuss with patients their lifestyle habits. Most patients quit or attempt to quit shortly after a cancer diagnosis, but still up to 50% of smoking cancer survivors continue to smoke."

Jassem also noted the following:

• Smoking increases the risk of a secondary primary cancer —The Retinoid Head and Neck Second Primary (HNSP) Trial found "the annual rates of tobacco-related second primary cancers in current, former, and never smokers were 4.2%, 3.2%, and 1.9%, respectively (P=0.03; current versus never smokers, P=0.02)."
• Patients with HNSCC who continue to smoke are more prone to "radiotherapy-induced complications, such as oral mucositis, weight loss, fatigue xerostomia, loss of taste and voice problems."
• HNSCC patients also have a lower response rate to radiation therapy and higher mortality than nonsmokers.

And if that’s not enough, Jassem also noted the following, again underscoring the importance of the "teachable moment" of the cancer diagnosis:

"Lung and head and neck cancer patients who quit smoking prior to their cancer diagnosis (recent quitters and former smokers) have better quality of life indices than survivors who continue smoking or quit smoking after their cancer diagnosis. Compared to never or former smokers, cancer patients who continued smoking have also poorer physical health, self-perception of their general health, emotional and social functioning, and vitality."

In Van Heest and colleagues’ study, their objective was to look at the frequency and patterns of smoking in patients after treatment for head and neck cancer. The participants in their study were diagnosed from Jan. 1, 2009 to Dec. 31, 2017, and were surveyed on their cigarette smoking prior to treatment initiation—number of cigarettes per day, how long they used tobacco, as well as number and frequency of daily alcoholic drinks. They were also asked if they tried to quit before, how many cessation attempts, the longest amount of time they were able to abstain, and their symptoms when trying to quit.

Exposures in the study included smoking at the time of diagnosis as well as having smoked at least 5 cigarettes/day for at least 5 years.

Demographic and clinical information, along with smoking and disease status, were gathered at four points—at 6 , 12, 18, and 24 months after treatment for HNSCC.

There were 89 patients enrolled in the trial who completed 24 months of post-treatment follow- up. Their mean age was 60.1 years, most were male (83.1%), and most were White (79.8%), while 3.4% were Black, 2.2% American Indian or Alaska Native, 1.1% Asian, and 13.5% of unknown race and ethnicity.

Among their results:

• At 6 months, 52 patients (58.4%) continued smoking after treatment, as did 47 (52.8%) at 12 months, 41 (46.1%) at 18 months, and 40 (44.9%) at 24 months.
• During the first 6 months, the probability of quitting was the highest—"0.36. Mean (SD) number of cigarettes per day (17.8 [9.6] versus 12.4 [10.0], mean difference, 5.1 [95%CI, 0.2 to 10.6]), duration of tobacco use (28.2 [18.1] versus 16.4 [17.4] years, mean difference, 11.8 [1.9 to 21.7] years), and lower number of prior quit attempts (5.3 [5.9] versus 10.4 [22.9], mean difference, −5.2 [95%CI, −15.7 to 5.4]) were all associated with persistent tobacco use at 24 months after treatment versus those who successfully quit," the researchers wrote.

"Patients who successfully quit smoking in the first 6 months were less likely to relapse at each subsequent time interval, with probabilities of remaining nonsmoking of 0.69 at 12 months, 0.71 at 18 months, and 0.92 at 24 months," Van Heest and colleagues wrote. "Furthermore, patients who successfully quit smoking during the first 6 months after treatment were most likely to relapse at 12 months (probability, 0.16). The probability of relapse then decreased over time, with probabilities of 0.07 at 18 months and 0.04 at 24 months after treatment."

The study authors also noted that the number or pre-treatment quit attempts was associated with a higher success in quitting attempts 24 months after treatment "with a small-to-moderate effect size of −0.35. The effect sizes are also likely to be clinically significant; smokers smoked an average of 5.1 more cigarettes per day for an average of 11.8 more years with an average of 5.2 fewer prior quit attempts compared with participants who successfully quit. These findings are helpful for identifying patients who are at higher risk for persistent smoking after treatment who could be targeted more aggressively with smoking cessation interventions."

Limitations of Van Heest et al’s study include the use of self-reported data, selection bias could have occurred because only those with long-term data were included, and data were incomplete at post treatment time points.

"Mortality, current smoking status, and the presence of active disease were the only variables collected at the post-treatment time points, which prohibits our ability to quantify and analyze attempted smoking cessation strategies and the granular details of tobacco use patterns throughout the follow- up period," the study authors wrote. Moreover, they pointed out that patients’ motivations for quitting or what aided successful quit attempts were not assessed during the study period.

This study was supported by a grant from the National Institutes of Health (NIH) using the Biostatistics and Bioinformatics Core shared resource of the Masonic Cancer Center, the University of Minnesota, and by an award from the National Center for Advancing Translational Sciences of the NIH.

Van Heest reported no relevant relationships.

Co-author Khariwala is Deputy Editor of JAMA Otolaryngology–Head & Neck Surgery, but was not involved in any of the decisions regarding review of the manuscript or its acceptance.

Van Heest T, et al "Persistent tobacco use after treatment for head and neck cancer" JAMA Otolaryngol Head Neck Surg 2022; DOI:10.1001/jamaoto.2022.0810