Abstract
Cancer survivors benefit from evidence-based smoking cessation treatment. A crucial first step in this process is a clinician recommending that the patient quit smoking. However, contemporary delivery of advice to quit among patients with cancer is not well known. In a cross-sectional analysis of all adult smokers included in a prospective population-representative study of US adults, we analyzed the frequency that patients reported receiving advice to quit smoking from a healthcare professional according to reported cancer history (no cancer, tobacco-related cancer, non-tobacco related cancer history). Among an estimated 28.3 million smokers, 9.3% reported a history of cancer, 48.8% of which were tobacco-related cancers. In general, advice to quit was reported by more (67.8%) cancer survivors than those adults without any cancer (56.0%). After adjustment for sociodemographic factors, smokers with a non tobacco-related cancer (0.51, 95% CI 0.32-0.83) and those without any cancer history (0.43, 95% CI 0.30-0.63) were both less likely to report being advised to quit smoking than patients with a tobacco-related cancer history.
Keywords: smoking cessation, cancer diagnosis, counseling
Introduction
Tobacco use is a leading cause of cancer and mortality in United States adults. Smoking cessation treatment is a critical component of cancer survivorship since those who quit have better outcomes and longer survival.1 Guideline recommended treatment includes clinician counseling and use of pharmacotherapy.2 Use of tobacco cessation counseling in the general population is well-described.3-7
The association between cessation rates after counseling amongst patients with and without cancer has been studied.8 Nevertheless, offering of cessation counseling, specifically for smokers with cancer, has been relatively understudied despite the established benefits in this vulnerable population.8-10 This is especially important given that continued smoking after a cancer diagnosis has been associated with poor outcomes.11
Understanding the prevalence and correlates of smoking cessation care given to cancer survivors at the population level can help inform future interventions aimed at improving the use of evidence-based treatments. Using a population-based cohort, we aim to determine whether adults with cancer are more or less likely to report being advised to quit smoking than those without cancer. Further, we aim to demonstrate that this recommendation is associated with the use of evidence-based pharmacotherapies.
Methods:
Study Design / Data Source
This is a cross-sectional secondary analysis of the Population Assessment of Health and Tobacco (PATH) study, a tobacco use survey administered to a representative population-based sample of United States adults. The survey includes questions related to tobacco use, demographic information, and health-related information including co-morbid conditions (i.e. cancer diagnosis). In order to enroll a representative sample of the United States population, respondents were recruited randomly on the basis of their home address, awarding $35 compensation for participation. The survey was weighted to the US population, and adjustments were made to address bias sources, including oversampling and non-response.12 Our analytic sample included all established adult smokers (currently smoking and >100 cigarettes in lifetime) at Wave IV (2017) who had seen a physician in preceding 12 months. We excluded those with missing data on smoking status (n=37), survey weights (n=50), and doctor visits in prior year (n=30).
Exposure and Outcome Measures
Our exposure of interest was history of a cancer diagnosis. This was determined by a “yes” response to the question “Has a doctor, nurse, or other health professional ever told you, you had cancer?” which was asked at each of the four survey (I-IV) waves and was dichotomized as either “yes” (any reported history of cancer) or “no” (no reported history of cancer). We categorized cancer history as a three-level exposure variable (tobacco-related cancer diagnosis, non-tobacco-related cancer diagnosis, or no cancer diagnosis). According to the PATH study investigator designation, reported cancer type was categorized to tobacco related: bladder, cervix, colon, esophagus, kidney, larynx, liver, lung, mouth, pancreas, rectum, stomach, and throat or non-tobacco related: blood, bone, brain, breast, gallbladder, leukemia, lymphoma, melanoma, nervous system, ovarian, prostate, non-melanoma, unknown skin, soft tissue, testicular, thyroid, uterine.
Our primary outcome was whether participants reported being advised to quit smoking by a healthcare professional based on a “yes” response to the question “In the past 12 months, did any doctor, dentist, or other healthcare professional advise you to stop using tobacco”. Based on the adaptive survey design, only participants who had contact with the healthcare system (a doctor, dentist, or ER/urgent care visit) in the prior year were asked about being advised to quit smoking. Secondary outcomes included use of smoking cessation pharmacotherapy such as nicotine replacement (NRT) or prescription drugs as determined by a “yes” response to “In the past 12 months, have you used…a nicotine patch, gum, inhaler, nasal spray, lozenge or pill?” or “…prescription drug: Chantix, varenicline, Wellbutrin, Zyban, or bupropion?”.
Data Analysis
Sociodemographic data including age, sex, BMI, race, region, income, insurance status, and education were included as covariates on the basis of the existing smoking cessation literature.4,13 Unadjusted weighted percentages of participants who reported being advised to quit were calculated for our three level exposure and for each covariate. Logistic regression was used to assess the association of being advised to quit smoking with cancer history, adjusting for participant-level sociodemographic covariates chosen a priori. For our secondary outcome, we used logistic regression to assess whether reported use of pharmacotherapy was associated with being advised to quit. This was performed to better understand if recommendations to quit were associated with use of evidence-based quit aids.
As a sensitivity analysis, since the survey prompt used for our primary outcome asked if “any doctor, dentist or healthcare professional” advised the participant to quit smoking (and not just doctor), we applied our primary regression model to the sample of smokers who reported any contact with the healthcare system (ER visit, dentist visit, and doctor visit rather than just doctor visit) in the prior 12 months to further test this association.
Population weighted percentages with 95% confidence intervals were estimated using survey commands for a cross-sectional analysis of a single wave in STATA v16 as recommended by the PATH study investigators.10 All statistics were performed with two-sided significance set to be <0.05. This study was waived from institutional IRB review.
Results:
Of all 33,822 adult study participants in Wave IV, 29.5% (n=9915) reported being an established current smoker at Wave IV. Of this cohort, 65.2% (n=6414) reported seeing a physician in the prior 12 months and comprised our analytic sample (weighted estimate of 28.3 million active smokers in 2017). Of all included smokers, 57.1% were advised to quit smoking by a healthcare provider. Among the 9.3% of participants reporting a history of cancer, 48.8% had a tobacco-related cancer. Of all respondents with a cancer history, 67.8% reported being advised to quit smoking. Those with a tobacco-related cancer were more often advised to quit smoking than those with a non-tobacco related cancer history (73.0% vs. 62.9%). Conversely, 56.0% of adults without a history of cancer reported being advised to quit smoking. Cigarette smokers with no history of cancer were less likely to report being advised to quit smoking (OR 0.43, 95% CI 0.30-0.63) compared to those with a history of a tobacco-related cancer history (Table 1). Similarly, patients with a history of non-tobacco-related cancer were less likely to report being advised to quit (OR 0.51, 95% CI 0.32-0.83). Results of the sensitivity analysis were consistent for both non-tobacco related cancers and those without a cancer history (OR 0.43, 95% CI 0.30-0.62, OR 0.51 95% CI 0.32-0.81, respectively).
Table 1 –
Characteristics of adult smokers who saw a doctor in the prior 12 months and unadjusted percentages and logistic regression results of receiving advice to quit smoking by a healthcare professional
| Weighted n for entire cohort |
Weighted % of entire cohort (95% CI) |
Unadjusted, weighted % advised to quit (95% CI) |
Adjusted OR of being advised to quit (95% CI) |
p | ||
|---|---|---|---|---|---|---|
| Cancer History | None | 25,670,639 | 90.7 (89.6-91.8) | 56.0 (54.2-57.8) | 0.43 (0.30-0.63) | <0.001 |
| Tobacco-related cancer | 1,280,489 | 4.5 (3.8-5.4) | 73.0 (62.4-81.5) | REF | - | |
| Non-tobacco related cancer | 1,345,062 | 4.8 (4.2-5.4) | 62.9 (56.2-69.2) | 0.51 (0.32-0.83) | 0.007 | |
| Age (in years) | 18-54 | 18,961,518 | 67.0 (65.5-68.5) | 53.4 (51.5-55.3) | REF | - |
| 55+ | 9,358,189 | 33.0 (31.6-34.5) | 64.6 (61.3-67.7) | 1.26 (1.06-1.51) | 0.01 | |
| Sex | Female | 14,942,951 | 52.7 (51.1-54.4) | 57.7 (55.6-59.7) | REF | - |
| Male | 13,376,753 | 47.3 (45.6-49) | 56.4 (53.7-59.1) | 1.01 (0.87-1.17) | 0.899 | |
| BMI category | Under/normal | 9,517,173 | 33.6 (32-35.2) | 54.0 (51.3-56.8) | REF | - |
| Over/obese | 18,802,534 | 66.5 (64.9-68) | 58.6 (56.7-60.6) | 1.20 (1.04-1.38) | 0.013 | |
| Marital Status | Never married | 8,911,620 | 31.6 (30.2-33.2) | 49.7 (47.2-52.2) | REF | - |
| Married | 10,107,720 | 35.9 (34.6-37.2) | 58.3 (56.1-65.2) | 1.27 (1.09-1.49) | 0.002 | |
| Widowed/Divorced/Separated | 9,192,259 | 32.5 (31.3-33.8) | 62.8 (59.7-65.9) | 1.48 (1.23-1.79) | <0.001 | |
| Race | White non-Hispanic | 19,895,684 | 70.2 (68.7-71.6) | 58.1 (56.1-60.1) | REF | - |
| Black non-Hispanic | 3,786,623 | 13.4 (12.4-14.5) | 61.8 (58.3-65.2) | 1.17 (0.99-1.39) | 0.06 | |
| Hispanic | 3,054,786 | 10.8 (9.9-11.9) | 45.2 (40.0-50.6) | 0.63 (0.48-0.83) | 0.001 | |
| Other | 1,582,614 | 5.6 (4.9-6.4) | 55.8 (50.0-61.4) | 0.96 (0.73-1.27) | 0.77 | |
| Region | Northeast | 4,945,700 | 17.5 (15.7-19.4) | 61.7 (57.9-65.4) | REF | - |
| Midwest | 7,188,209 | 25.4 (23.5-27.4) | 59.3 (56.3-62.3) | 0.82 (0.66-1.01) | 0.059 | |
| South | 11,311,252 | 39.9 (37.8-42) | 56.2 (53.4-59.0) | 0.79 (0.64-0.97) | 0.025 | |
| West | 4,874,546 | 17.3 (15.7-19) | 51.2 (47.5-54.8) | 0.69 (0.55-0.86) | 0.001 | |
| Income | <$25,000 | 12,663,120 | 47.2 (45.6-48.8) | 68.6 (56.4-60.8) | REF | - |
| $25,000-49,999 | 6,192,276 | 23 (21.7-24.5) | 57.1 (53.9-60.3) | 0.97 (0.81-1.15) | 0.75 | |
| $50,000-99,999 | 5,582,673 | 20.8 (19.5-22.2) | 57.7 (54.0-61.2) | 0.98 (0.78-1.18) | 0.84 | |
| >$100,000 | 2,422,086 | 9.0 (8-10.1) | 52.3 (47.2-57.4) | 0.86 (0.66-1.12) | 0.26 | |
| Education | Did not graduate HS | 4,160,496 | 14.8 (13.7-15.9) | 58.7 (54.6-62.7) | REF | - |
| HS Grad +/− some college | 20,521,275 | 72.8 (71.5-74.1) | 57.9 (56.2-59.7) | 0.92 (0.78-1.09) | 0.34 | |
| College grad or advanced | 3,511,610 | 12.4 (11.4-13.5) | 49.9 (45.2-54.6) | 0.66 (0.51-0.85) | 0.002 | |
| Insured | No | 3,378,143 | 12.0 (11.2-12.9) | 42.9 (38.6-47.3) | REF | - |
| Yes | 24,766,545 | 88.0 (87.1-88.8) | 59.1 (57.3-60.8) | 1.68 (1.37-2.06) | <0.001 |
Notes: Cohort includes adult smokers who reported seeing a doctor in the 12 months prior to the Wave IV in the Population Assessment of Tobacco or Health survey (raw n=6414, weighted n=28,319,707)
CI: Confidence Interval; OR: Odds Ratio
For our secondary outcome, 18.1% of our sample reported using approved pharmacotherapy in the prior 12 months (23.4% who were advised to quit vs. 10.9% who were not). Those who were advised to quit by a healthcare professional had a higher adjusted odds (OR 2.26, 95% CI 1.95-2.61) of using pharmacotherapy (Table 2). Having no history of cancer, or a history of non-tobacco-related cancer were each independently associated with a lower odds of reporting use of pharmacotherapy in the past year.
Table 2-.
Adjusted odds of all included smokers’ use of pharmacotherapy (NRT or prescription medications) in the past 12 months and being advised to quit by a healthcare professional during that time period.
| Adjusted Odds Ratio for use of approved pharmacotherapies (95% CI) |
P | ||
|---|---|---|---|
| Advised to quit | No | REF | - |
| Yes | 2.26 (1.95-2.61) | <0.001 | |
| Cancer History | None | 0.48 (0.33-0.69) | <0.001 |
| Tobacco-related cancer | REF | - | |
| Non-tobacco related cancer | 0.75 (0.44-1.26) | 0.28 | |
| Age | 18-54 | REF | - |
| 55+ | 1.25 (1.03-1.53) | 0.026 | |
| Sex | Female | REF | - |
| Male | 0.85 (0.73-0.98) | 0.023 | |
| BMI | Under/normal | REF | - |
| Over/obese | 1.14 (1.00-1.31) | 0.057 | |
| Marital Status | Never married | REF | - |
| Married | 1.01 (0.84-1.22) | 0.92 | |
| Widowed/Divorced/Separated | 1.00 (0.80-1.25) | 0.99 | |
| Race | White HS | REF | - |
| Black HS | 0.78 (0.62-0.99) | 0.037 | |
| Hispanic | 0.55 (0.40-0.74) | <0.001 | |
| Other | 0.99 (0.67-1.45) | 0.94 | |
| Region | Northeast | REF | - |
| Midwest | 0.95 (0.70-1.28) | 0.73 | |
| South | 0.96 (0.71-1.32) | 0.84 | |
| West | 1.12 (0.84-1.51) | 0.44 | |
| Income | <$25,000 | REF | - |
| $25,000-49,999 | 1.03 (0.81-1.32) | 0.80 | |
| $50,000-99,999 | 0.93 (0.75-1.15) | 0.49 | |
| >$100,000 | 1.09 (0.83-1.44) | 0.52 | |
| Education | Did not graduate HS | REF | - |
| HS Grad +/− some college | 0.82 (0.64-1.05) | 0.11 | |
| College grad or advanced | 0.92 (0.65-1.29) | 0.61 | |
| Insured | No | REF | - |
| Yes | 1.29 (0.92-1.80) | 0.14 |
Discussion:
In this representative population-based analysis of adult smokers in the United States, only 57% of active smokers who had seen a doctor in the year prior reported being advised to quit smoking by a healthcare professional. These results suggest a modest improvement compared to a 2008 U.S. Department of Health and Human Services update, which reported that 40% of smokers were advised to quit by their provider.14 Although adults with a history of cancer were more likely to report receiving a recommendation to quit smoking than those without cancer, more than one third (33%) of these adults did not report receiving advice from a health professional to stop smoking in the past 12 months. These results are similar to a previous study in which only 61% of surveyed oncologists reported providing smoking cessation advice.15 In our study, respondents who reported being advised to quit by a healthcare professional had over twice the odds of using evidence-based smoking cessation pharmacotherapy, demonstrating the potential impact healthcare providers’ recommendations have on patients’ attempts to quit. These findings support a prior systematic review, including 26 trials (representing ~22,000 respondents), which reported an 8% cessation rate amongst those receiving physician advice versus a 4.8 % cessation rate amongst those receiving usual care.16 We found that patients with a history of a tobacco-related cancer were more likely to be advised to quit smoking and were more likely to utilize pharmacotherapies to assist with cessation. These findings are similar to a prior study, which demonstrated that patients with a tobacco-related cancer receive cessation counseling at a higher rate than patients with a non-tobacco-related cancer.17 This presents an opportunity to improve smoking cessation efforts, as targeting cessation efforts towards patients without cancer history, or with non-tobacco-related cancer history should be considered equally important.
In our study, certain demographics were associated with a higher or lower likelihood of receiving advice to quit smoking. For example, older patients, and those with obesity reported higher odds of receiving advice to quit. This may be due, in part, to an increased number of physician visits amongst these respondents, or a perceived higher risk of acquiring a smoking-related diagnosis.18 However, Hispanic patients reported lower odds of being advised to quit smoking. This may be due to implicit bias within the healthcare system or may also be due to provider-patient language barriers,19 as cessation advice provided in the preferred language has been shown to improve patient comprehension and subsequent cessation rates.20 With regard to regional differences, a prior study speculated that this may be due to the higher prevalence of smoking in the South, in particular.4 Lastly, uninsured patients were less likely to receive advice to quit, which may represent poor access to healthcare or evidence-based pharmacotherapies. This demonstrates an even greater role and impact to be made through publicly available free resources such as 1-800-QUIT-NOW.
With regard to the likelihood of using of approved pharmacotherapies, results were demographically similar to those receiving advice to quit. Notable exceptions include Black non-Hispanic race, which was associated with lower odds of utilization. This may be due to lack of trust in the healthcare system or access disparities. Region, income level, educational attainment and insurance status were not associated with a difference in utilization of pharmacotherapies.
Overall, it is encouraging that healthcare providers are more likely to advise patients with cancer to quit smoking given the well-established benefits. Smoking cessation is an essential component of comprehensive cancer care and is universally recommended by physician societies and patient advocacy groups.8,12 However, our findings also highlight the sizable proportion of cancer patients who have not been counseled to quit. This may present an opportunity for improvement, as these findings demonstrate that smoking cessation counseling is underutilized. Further, given the association between counseling and treatment, the patients not receiving cessation counseling may also be undertreated. Our findings are comparable to that of a recent National Health Interview Survey (NHIS) study which demonstrated that around half (54.9%) of smokers in 2015 reported receiving advice to quit. Our study is notable, however, in its highlight of the underutilization of smoking cessation in a vulnerable group of smokers with a history of cancer.4 Smoking cessation remains important in these patients as continued smoking has been associated with poorer prognostic outcomes.11
Limitations
There are several limitations and strengths worth noting in our approach. Foremost, all data was self-reported introducing the potential for reporting/recall bias and inaccuracy. Cancer history could not be verified, and the actual delivery of smoking cessation counseling cannot be determined outside of what was reported by the respondent. However, smoking cessation advice can safely be considered ineffective if it was not recalled or perceived by the patient.21 Additionally, due to survey design we were limited to analysis among adults who had seen a doctor in the prior year. This may limit the translatability of our findings to only those who seek out or have access to healthcare, inherently biasing our results and overestimating the frequency of smoking cessation counseling provided, in general. However, our study was performed to inform future physician-given interventions in the outpatient setting.
Conclusions:
Despite observing that smokers with a cancer diagnosis were relatively more likely to report being advised to quit smoking by healthcare professionals, these current, nationally representative rates of counseling indicate missed opportunity to target this vulnerable population of smokers. Future research regarding the best means of implementing evidence-based smoking cessation solutions is needed, particularly among patients with cancer, as continued smoking is associated with poor outcomes.
Highlights:
Smokers with a cancer diagnosis are more likely to be advised to quit smoking
One-third of smokers with cancer history did not receive cessation counseling
Smokers receiving cessation counseling were twice as likely to receive pharmacotherapy
Acknowledgements:
Funding
Dr. El Shahawy’s time is partially supported by a fellowship grant from the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) and the Food & Drug Administration’s (FDA) Center for Tobacco Products (CTP) under Award Numbers P50HL120163 and U54HL120163. There are no funding sources to report for any other authors for this work.
Footnotes
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Conflicts
The authors report no conflicts of interest, financial or otherwise. All authors provided sufficient contributions to merit authorship.
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