pISSN 0513-5796   eISSN 1976-2437
Open Access, Peer-reviewed, Monthly
    Yonsei Med J. 2023 Apr;64(4):251-258. English.
    Published online Mar 24, 2023.
    https://doi.org/10.3349/ymj.2022.0499
    © Copyright: Yonsei University College of Medicine 2023
    Original Article

    Effective Timing of Introducing an Inpatient Smoking Cessation Program to Cancer Patients

    Yu-Ri Choe,1,2,3 Ji-Won Choi,1 Ju-Ri Jeong,1 Hye-Mi Doh,1 Mi-Lee Kim,1 Min-Seol Nam,2 Hee-Ji Kho,4 Ha-Young Park,2,5 Hye-Ran Ahn,2,7 Sun-Seog Kweon,2,6 Yu-Il Kim,2,5 and In-Jae Oh2,4,5
      • 1Department of Family Medicine, Chonnam National University Hwasun Hospital, Hwasun, Korea.
      • 2Chonnam Tobacco Control Center, Chonnam National University Hwasun Hospital, Hwasun, Korea.
      • 3Department of Family Medicine, Chonnam National University Medical School, Gwangju, Korea.
      • 4Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Hwasun, Korea.
      • 5Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea.
      • 6Department of Preventive Medicine, Chonnam National University Medical School, Gwangju, Korea.
      • 7Department of Nursing, Nambu University, Gwangju, Korea.
    • Corresponding author: In-Jae Oh, MD, PhD, Department of Internal Medicine, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun 58128, Korea. Email: droij@chonnam.ac.kr
    Received November 15, 2022; Revised January 22, 2023; Accepted January 26, 2023.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Abstract

    Purpose

    We aimed to identify factors influencing smoking cessation success among cancer patients registered in an inpatient smoking cessation program at a single cancer center.

    Materials and Methods

    The electronic medical records of enrolled patients with solid cancer were retrospectively reviewed. We evaluated factors associated with 6-month smoking cessation.

    Results

    A total of 458 patients with cancer were included in this study. Their mean age was 62.9±10.3 years, and 56.3% of the participants had lung cancer. 193 (42.1%) had not yet begun their main treatment. The mean number of counseling sessions for the participants was 8.4±3.5, and 46 (10.0%) patients were prescribed smoking cessation medications. The 6-month smoking cessation success rate was 48.0%. Multivariate analysis showed that younger age (<65 years), cohabited status, early stage, and the number of counseling sessions were statistically significant factors affecting 6-month smoking cessation success (p<0.05). Initiation of a cessation program before cancer treatment was significantly associated with cessation success (odds ratio, 1.66; 95% confidence interval, 1.02–2.70; p=0.040).

    Conclusion

    Smoking cessation intervention must be considered when establishing a treatment plan immediately after a cancer diagnosis among smokers.

    Keywords
    Cancer; inpatients; lung cancer; smoking cessation

    INTRODUCTION

    As the 5-year relative survival rate of cancer patients has increased, from 51.1% in 2002 to 69.8% in 2014,1, 2, 3 risk factor management for cancer survivors is becoming more important. Among various risk factors, smoking among cancer patients is closely associated with adverse outcomes, including an increased risk of second primary cancer, postoperative complications, overall increased mortality/decreased efficacy, treatment tolerance (radiation, systemic therapy), and decreased health functioning and quality of life.4, 5, 6 Multiple clinical practice guidelines by oncology organizations emphasize smoking cessation in all patients with cancer and suggest that smoking cessation should be considered in cancer treatment.7, 8, 9

    A cancer diagnosis can serve as an impetus for quitting smoking.10 Research has shown that patients typically have a heightened interest in smoking cessation and are highly motivated to do so after a cancer diagnosis and that appropriate healthcare interventions significantly increase the success rate of smoking cessation.10, 11, 12 However, 10%–30% of patients diagnosed with cancer continue to smoke,13, 14 and more than half of the people who smoked prior to being diagnosed with cancer continue to do so.4, 15 In Korea, the current smoking rate of the general adult population is estimated to be 25.8% (males: 44.7% and females: 6.6%), while the current smoking rate among cancer survivors is estimated to be 10.5% (males: 22.1% and females: 2.3%).1

    There are clinical guidelines covering smoking cessation treatments for cancer patients:7, 8, 9 assess and document the current cigarette smoking status of all patients with cancer, engage patients in motivational dialog about smoking cessation, and establish a personalized quit plan.7 However, individualized screening and counseling are not occurring,16, 17 and appropriate smoking cessation treatment by healthcare professionals is lacking.18, 19 Moreover, previous studies have reported that even in patients who have been recommended to receive smoking cessation treatment, various factors, such as disease severity, low self-efficacy, age, and partner status, interfere with starting smoking cessation treatment.16, 20 Patients who had been recommended smoking cessation treatment after cancer diagnosis showed treatment acceptance rates of 17%–84%.21, 22, 23, 24 Moreover, one study reported that there is no major difference in smoking cessation success rates between cancer patients and non-cancer patients,16 indicating that cancer diagnosis is not being properly utilized as a teachable smoking cessation moment. Therefore, strategic approaches for utilizing cancer diagnosis to initiate smoking cessation programs must be developed.

    In 2015, an inpatient smoking cessation program supported by the National Health Insurance Service was started in Korea for hospitalized patients.25 Patients enrolled in this program are provided intensive smoking cessation bedside and telephone counseling, exhaled carbon monoxide level and/or urine cotinine tests, behavioral reinforcement (tooth-brushing set, mouthwash, educational handbooks, candies, etc.), and if needed, smoking cessation treatment [nicotine replacement therapy (NRT) or prescription medication].

    In this study, we aimed to identify factors influencing smoking cessation success among cancer patients registered in an inpatient smoking cessation program at a single cancer center. We also aimed to identify the influence of when the smoking cessation intervention is introduced (before vs. after primary cancer treatment) on smoking cessation success rates.

    MATERIALS AND METHODS

    Participants

    Among 1631 patients who were referred to the inpatient smoking cessation program at Chonnam National University Hwasun Hospital (CNUHH) between May 1, 2017 and December 31, 2020, 608 patients were enrolled in the inpatient smoking cessation program. Of these 608 patients, we selected 458 patients who were diagnosed with cancer (431 males and 27 females) for this study (Fig. 1). Patient information was obtained from the electronic medical record (EMR) system and questionnaires. This study was approved by the CNUHH Institutional Review Board (CNUHH-2021-098), and informed consent was obtained from all subjects involved in the study.

    Fig. 1
    Flowchart of participants.

    The smoking cessation program process

    At CNUHH, the smoking status of all inpatients is assessed before hospitalization, and smokers are referred to the inpatient smoking cessation program when necessary. Of these patients, those who wished to enroll in the program were required to complete and submit an enrollment consent form and questionnaires assessing smoking status and nicotine dependence. The questionnaire included items related to age at smoking commencement, average daily smoking amount, total duration of smoking years, and confidence in smoking cessation. Confidence in smoking cessation was rated on a Likert scale (0–10 points) using the self-reporting question “How confident are you that you could stop smoking?” Higher scores indicate a higher level of confidence in smoking cessation.26 Nicotine dependence was assessed using the Korean version of the Fagerström Test for Nicotine Dependence (FTND-K).27

    During the hospitalization period, a trained nurse or counselor provided smoking cessation counseling, behavioral reinforcement items, and when necessary, NRT or medication.25 After discharge, the patients received at least eight additional counseling sessions (four person-to-person and four telephone sessions) over 24 weeks, regardless of smoking cessation success/failure status. The follow-up counseling sessions were designed to identify whether the patients were maintaining smoking cessation, if they had any withdrawal symptoms and how they coped with such symptoms, if they required any smoking cessation medications, and if they had any side effects from these medications. Smoking cessation success was determined based on self-reported smoking status after 2, 4, 6, 12, and 24 weeks. In addition, smoking status was also verified by exhaled carbon monoxide levels and/or urine cotinine tests after 4 and 24 weeks. In this study, 6-month smoking cessation success was defined as continuously maintaining smoking cessation during follow-up counseling at 2, 4, 6, 12, and 24 weeks.

    Timing the initiation of a cessation program

    The timing of cessation program initiation was identified retrospectively through a review of the EMR system. The participants were divided into two groups: “before cancer treatment” for those who were admitted for cancer diagnosis and staging and “after cancer treatment” for those who were admitted for cancer treatment, such as any procedure, surgery, chemotherapy, and radiation, or those admitted for management of symptoms and complications that occurred during treatment.

    Other covariate

    The self-reported questionnaire for enrollment in the inpatient program included covariates other than smoking status, such as demographic variables (age, sex, employment status, cohabitation status, and educational level) and health-related factors [body mass index (BMI), alcohol intake, exercise, and comorbidities]. Employment status was divided into two groups: “employed” and “unemployed,” based on job status at the time of hospitalization. Cohabitation status was divided into “cohabited” and “not cohabited.” Education level was divided into five groups: “non-response,” “under middle school,” “under high school,” and “over college” according to each subject’s level of education.

    BMI was calculated based on weight and height measured at the time of hospitalization, and the participants were divided into underweight, (<18.5 kg/m2), normal weight (18.5 kg/m2≤BMI<23 kg/m2), overweight (23 kg/m2≤ BMI <25 kg/m2), and obese (≥25 kg/m2).28 Alcohol consumption was divided into two groups of “over-moderate drinking” and “moderate drinking” based on the frequency of alcohol consumption and the amount (servings) of alcohol consumed per sitting.29 Moderate drinking for Koreans is defined as ≤eight and ≤four servings/week for male aged ≤65 and >65 years, respectively, while that of female is half that of male. One standard serving contains 14 g of alcohol. Comorbidities included hypertension, diabetes, dyslipidemia, coronary artery disease, cerebrovascular disease, respiratory system disease (pneumonia, chronic obstructive pulmonary disease, and tuberculosis), psychiatric disease, liver disease (hepatitis B, hepatitis C, and cirrhosis), and other previously diagnosed cancers other than the recently diagnosed cancer. Participants were divided into two groups: those with one or more comorbidities and those with none. In addition, the type of cancer diagnosed and cancer stage were checked, and the cancer stage was classified according to the American Joint Committee on Cancer 8th ed. Tumor, node, metastasis staging classification.30

    Statistical analysis

    We divided all participants into “success” and “fail” groups according to 6-month smoking cessation status. To compare the two groups, we conducted an independent samples t-test for continuous variables and a chi-square test for categorical variables. To identify predicting factors for 6-month smoking cessation, a logistic regression model was used for the univariate and multivariate analyses. In multivariate analysis, age, sex, and variables that were significant in univariate analysis (cohabitating status, confidence in smoking cessation, cancer stage, timing of initiation of smoking cessation program, and number of counselling) were included. All statistical analyses were performed with R (version 4.1.1; R Foundation for Statistical Computing, Vienna, Austria). P values <0.05 were considered statistically significant.

    RESULTS

    Baseline characteristics

    The baseline characteristics of the study participants are presented in Table 1. A total of 458 patients with cancer were included in this study (431 male and 27 female). Their mean age was 62.9±10.3 years. Most patients were employed (59.6%) and in a cohabited (89.3%) state at the time of registration and did not answer the questions regarding their education level (57.5%). Regarding the participant’s BMI, 135 (29.5%) were underweight, 135 (29.5%) were normal weight, 73 (15.9) were overweight, and 115 (25.1) were obese. Most participants consumed a moderate amount of alcohol (60.3%), and a total of 294 (64.2%) participants had one or more comorbidities. The mean smoking amount was 43.7±22.5 pack-years, and the mean confidence score in smoking cessation was 8.0±2.3 points. By FTND-K, 103 (22.5%) had a low dependence, 238 (52.0%) a moderate dependence, and 117 (25.5%) a high dependence on nicotine. More than half of the participants had lung cancer (56.3%). Table 2 summarizes the primary cancer sites of participants. A total of 19.7%, 15.7%, 34.3%, and 30.3% of patients were in cancer stages I, II, III, and IV, respectively. Most participants were in their first hospitalization (80.6%), and 193 (42.1%) had not yet started their main treatment. There were 8.4±3.5 counseling sessions per participant. Seven (1.5%) patients used NRT, and 46 (10.0%) patients were prescribed smoking cessation medications.

    Table 1
    Demographic and Clinical Characteristics of the Participants (n=458)

    Table 2
    Primary Cancer Sites among the Participants

    Six-month smoking cessation success

    A total of 366 (79.9%) patients succeeded in smoking cessation for 2 and 4 weeks; 335 (73.1%), 289 (63.1%), and 220 (48.0%) patients succeeded in smoking cessation for 6, 12, and 24 weeks, respectively (Table 1). The characteristics of the participants who stopped smoking for 6 months are summarized in Table 3.

    Table 3
    Characteristics of the Participants with 6-Month Smoking Cessation

    Factors associated with success of 6-month smoking cessation

    In univariate analysis, cohabitation status, high confidence in smoking cessation, initiation of a cessation program before cancer treatment, early cancer stage, and the number of counseling sessions were significantly associated with the success of 6-month smoking cessation (p<0.05) (Table 3). Multivariate analysis included the variables that were significant in the univariate analysis in addition to age and sex. After adjusting for these variables, younger age (<65 years), cohabited status, cancer stage (stage I–III), and the number of counseling sessions were statistically significant for 6-month smoking cessation success (p<0.05) (Table 4). Initiation of a cessation program before cancer treatment was also significantly associated with smoking cessation (odds ratio, 1.80; 95% confidence interval, 1.12–2.88; p=0.014).

    Table 4
    Multivariate Analysis of Factors Associated with Success of 6-Month Smoking Cessation

    DISCUSSION

    In this study, we confirmed that the smoking cessation success rate differs according to when the smoking cessation intervention is initiated in cancer patients. Initiating an intensive smoking cessation program before primary cancer treatment begins influences 6-month smoking cessation success.

    In this study, the 6-month smoking cessation success rate for all participants was 48.0%, which was similar to rates reported in previous studies.4, 15 The pre- and post-treatment intervention groups showed success rates of 53.9% and 43.8%, respectively. A previous study demonstrated that patients who have not started their treatment have a stronger motivation for smoking cessation than cancer survivors who are in the middle of or completed treatment due to significant anxiety and fear of death that they experience when diagnosed with cancer.31 Another study defined this as the readiness phenomenon32 in which most patients who voluntarily refrained from smoking cigarettes did so because of their cancer diagnosis and advice from their physician regarding how cigarettes could hinder treatment outcomes and prognosis. This phenomenon reflects cessation due to a recent cancer diagnosis and the resulting fear of additional disease. Moreover, research indicates that the motivation for smoking cessation decreases over time after a cancer diagnosis, wherein patients in the recovery stage lose their will to comply with health recommendations, such as smoking cessation, as they became less aware of the seriousness of their disease as their symptoms improve.24

    Furthermore, cancer patients who continue to smoke did not recognize how smoking can exacerbate their disease, decrease cancer treatment effects, and cause other smoking-related cancers, cancer recurrence, and various complications.33 These results suggest that long-term smoking cessation success may depend on educating patients on how smoking can adversely affect their health and treatment before intensive treatment. In conclusion, our findings demonstrated that smokers diagnosed with cancer who received smoking cessation intervention before treatment initiation showed a higher 6-month smoking cessation success rate. This suggests that active attempts for smoking cessation, such as smoking cessation programs, must be considered for cancer patients at the treatment planning stage in clinical practice.

    Other factors influencing the six-month smoking cessation success included younger age (≤65 years), early stage of cancer, cohabitation status, and the number of counseling sessions. Although the reported effects of age and stage of cancer on smoking cessation vary,16, 20 younger smokers have fewer comorbidities and may have a greater interest in smoking cessation owing to other social factors (family and employment).20 Moreover, patients in the early stages of cancer may be in good general condition and have a positive view of their prognosis and greater interest in smoking cessation than those in a later stage of cancer who may feel hopeless.20 Patients who live with someone, including a spouse, showed a higher 6-month smoking cessation success rate. Factors associated with the home environment may have a significant influence on smoking cessation, and people who are divorced or who have never been married are less likely to quit smoking than married people.34 In addition to unmarried respondents, respondents who lacked social support were also less likely to quit smoking. From a home-support perspective, having a cohabitant is an important consideration for smoking cessation treatment.35, 36 This association was more prominent among male.35 Considering that most of the participants in our study were male (94%), this association may have been emphasized in our results. Moreover, participants with more smoking cessation counseling sessions showed a higher 6-month smoking cessation success rate. Previous studies also showed that having more smoking cessation counseling sessions is associated with a higher smoking cessation success rate and demonstrated the usefulness and effectiveness of brief and frequent counseling.31, 37 Therefore, regular smoking cessation counseling is important in clinical practice for maintaining long-term smoking cessation, while continued efforts by professional counselors are also important.

    This study had some limitations. First, the inpatient smoking cessation program checked smoking status during counseling at 2, 4, 6, 12, and 24 weeks based on a self-reported questionnaire. In addition, smoking cessation status was also assessed objectively by urine cotinine and/or an exhaled carbon monoxide level tests performed at 4 weeks and 6 months. However, due to the COVID-19 pandemic, face-to-face counseling became difficult after January 2020. Actual urine cotinine and/or exhaled carbon monoxide level measurements were taken in only 58.5% of cases. Therefore, this study had limited objective test results. Six-month smoking cessation was defined as self-reported smoking cessation status during follow-up counseling at 2, 4, 6, 12, and 24 weeks. Using a self-reported questionnaire limits data collection, as it is not a direct and complete method, compared to in-person examinations. Future studies that address these issues may obtain more meaningful results. Second, this study set 6-month smoking cessation success rate as the primary outcome. However, this would not sufficiently reflect complete smoking cessation success. However, a review of previous studies of long-term smoking cessation showed that many studies have conducted at least 6 months of follow-up, and most considered 6-month smoking cessation and beyond to be related to long-term smoking cessation success.38 Moreover, another study reported that those who maintained smoking cessation for at least 6 months were more than twice as likely to maintain smoking cessation for more than 18 months than those who did so for less than 3 months.39 Maintaining smoking cessation for at least 6 months is significant for long-term smoking cessation success.40 Moreover, identifying the initiation time for smoking cessation intervention based on the 6-month smoking cessation success rate is significant. However, long-term studies that include at least 5 years of treatment for cancer patients or follow-up after complete remission may provide results on the association between the initiation of a smoking cessation intervention and the health or quality of life of cancer survivors. Lastly, the data collected in this study were from a single center, which allows for data collected by a consistent protocol and program, but biases associated with regional characteristics and patient groups cannot be dismissed. In the future, additional systematic and diverse studies based on broader data collected from multiple centers are warranted.

    Despite these limitations, our study is valuable in that although previous studies have discussed smoking cessation status after a cancer diagnosis, the importance of smoking cessation, and factors associated with smoking cessation success, there have been no large-scale studies to analyze differences in 6-month smoking cessation success rate according to the initiation time of smoking cessation intervention among cancer patients. In our study, we analyzed the differences in 6-month smoking cessation success rate according to the initiation time of the intervention among cancer patients. Our findings demonstrated that the 6-month success rate is statistically significant when smoking cessation intervention is initiated before cancer treatment. Our work highlights the need to establish a smoking cessation intervention immediately after a cancer diagnosis. Also, active smoking cessation intervention must include smoking cessation clinics.

    Notes

    The authors have no potential conflicts of interest to disclose.

    AUTHOR CONTRIBUTIONS:

    • Conceptualization: Yu-Ri Choe, Ji-Won Choi, and In-Jae Oh.

    • Data curation: Ju-Ri Jeong, Mi-Lee Kim, Min-Seol Nam, and Hee-Ji Kho.

    • Formal analysis: Yu-Ri Choe, Ji-Won Choi, and In-Jae Oh.

    • Funding acquisition: Sun-Seog Kweon.

    • Investigation: Ju-Ri Jeong, Hye-Mi Doh, Mi-Lee Kim, Min-Seol Nam, and Hee-Ji Kho.

    • Methodology: Yu-Ri Choe, Ji-Won Choi, and In-Jae Oh.

    • Project administration: Yu-Ri Choe, Sun-Seog Kweon, and In-Jae Oh.

    • Resources: Ha-Young Park and Hye-Ran Ahn.

    • Software: Yu-Ri Choe and Min-Seol Nam.

    • Supervision: Hye-Ran Ahn, Sun-Seog Kweon, Yu-Il Kim, and In-Jae Oh.

    • Validation: Ha-Young Park, Hye-Ran Ahn, and Sun-Seog Kweon.

    • Visualization: Yu-Ri Choe and In-Jae Oh.

    • Writing—original draft: Yu-Ri Choe, Ji-Won Choi, and Hye-Mi Doh.

    • Writing—review & editing: Yu-Ri Choe and In-Jae Oh.

    • Approval of final manuscript: all authors.

    ACKNOWLEDGEMENTS

    The authors would like to thank to all staffs of Jeonnam Tobacco Control Center and Korean Tobacco Control Center.

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    MeSH Terms
    Counseling
    Diagnosis
    Electronic Health Records
    Humans
    Inpatients*
    Lung Neoplasms
    Multivariate Analysis
    Program*
    Retrospective Studies
    Smoke*
    Smokers
    Smoking Cessation*
    Smoking*
    Metrics
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