Quantitative
Seventy-seven patients were identified as eligible for the study, with 64 consenting to participate, resulting in a response rate of 83%. Twenty-nine (45%) of these were current smokers, 24 (38%) were former smokers and 11 (17%) had never smoked. There was an equal distribution of early (stage I-II 50%) and advanced stage cancers (stage III-IV 50%). Six patients (9%) were treated with surgery alone, eight (13%) received adjuvant radiation after surgery and 50 (78%) had primary radiotherapy. Further demographic details of the overall population of current and former/never smokers are described in Table 1.
1. Current vs Former/Never Smokers
The initial analysis compared the baseline characteristics of current smokers with those who were former or never smokers (Table 1). The analysis identified that participants who were current smokers at diagnosis were more likely to live in a rural location (p = 0.015), have lower levels of education (p = 0.047), and report reduced social and family well-being (p = 0.005) when compared with those who were former or never smokers. Current smokers had a higher pack year history (45 vs 26, p = 0.005) and a lower proportion who were p16 positive (35% vs 66%, p = 0.013), indicating a lower percentage of HPV-associated tumours. There was also an increased proportion of oral cavity cancers in the current smoker group (31% vs 9%, p = 0.021).
2. Smoking Cessation Rates
Table 2 outlines the continuous and 7-day point prevalence cessation rates at 1 and 3 month follow-up. Only 26 of the 29 current smokers were able to be classified as a ceased or continued smoker. Two participants died before 1 month follow-up and one had not reached 1 month follow-up at the time of analysis. The continuous cessation rates were 54% at 1 month and 42% at 3-month follow up, and the 7-day point prevalence cessation rates were 72% at 1 month and 67% at 3 month follow-up. This demonstrated that a number of patients were able to actively achieve cessation at some stage in their treatment journey, but relapses were common.
3. Continuing vs Ceased Smokers
As highlighted in Table 3, there were 15 patients classified as continuing smokers and 11 as ceased smokers (3 month continuous cessation rate). Patients who continued smoking were more likely to consume more alcohol (p = 0.032), be less confident of being able to cease smoking (p = 0.004) and be in a lower stage of change (pre-contemplation or contemplation) of the transtheoretical model at baseline (p = 0.012). There was also higher psychological distress amongst patients who continued to smoke, but this was of borderline significance (K10 19.2 vs 14.7, p = 0.052).
Qualitative
The one-on-one interviews were performed with 5 ceased smokers and 10 continued smokers based upon the continuous cessation definition. However, only 6 reported actively smoking at the time of the interview. There were 13 males and 2 females interviewed, with a mean age and pack year history that was similar to that of the overall current smoker cohort. Thematic analysis of the data led to the identification of 5 key themes: The teachable moment of a cancer diagnosis and treatment, willpower and cessation aids, psychosocial environment, relationship with alcohol and marijuana and interaction between health knowledge and beliefs surrounding smoking and cancer. These themes are described below, with pertinent quotes used to illustrate their meaning; further quotes exemplifying each theme are also described in Table 4. Using the health beliefs model as a framework, Figure 2 highlights the important perceived benefits and barriers to smoking cessation that were evident throughout the interviews, which will be further explored in the discussion.
1. Teachable moment of cancer diagnosis and treatment
This theme encompassed the initial motivating factor that a HNC diagnosis provided, in addition to the role of treatment and its associated side effects in smoking cessation. The role of healthcare practitioners in providing patients with information surrounding smoking cessation was also a significant component of this theme. For patients unable to achieve cessation, there were a number of identifiable periods in which the teachable moment was not observed or unable to be sustained for extended periods of time. However, most patients were able to recount the impact that a HNC diagnosis had on their ability to quit smoking:
“This was just the trigger, whether it was the doctor or the nicotine patches or the operation, or the word cancer, they were all triggers that goes ‘oh well, this is what I’ve been trying to do the last couple of years so let’s go”
Irrespective of their smoking status after treatment completion, patients commonly described being able to cease smoking whilst undergoing treatment, particularly for those undergoing radiotherapy. This was outlined as a combination of not wanting to compromise their treatment, being too unwell to smoke because of the side effects of radiotherapy, and the fear of being discovered by the weekly exhaled carbon monoxide readings.
“You got the treatment, you can’t smoke. Simple as that. Because every time I had it [treatment], they had that CO2 puffer. You can’t lie. So, what’s the use of, you know, trying to hide one a few hours before. And I thought well I’m going to get caught out why just not have it.”
The impact of having a smoking-related cancer diagnosis was highlighted by some participants as a motivator for cessation. Patients also identified that a diagnosis of head and neck cancer was a more convincing motivator for contemplating smoking cessation compared with other previous health conditions they had experienced, which included myocardial infarctions and valve replacements.
“Even the heart business [coronary artery bypass graft surgery], after it didn’t hurt when I coughed anymore. Within a month or two I would have had one more [smoke] and that’s it. But no more now.”
2. Willpower and cessation aids
Willpower and its interaction with both pharmacological and non-pharmacological aids was identified as an important contributor to achieving cessation. Some patients attempted to cease ‘cold turkey’ and cited their own willpower as the reason for their success.
“I actually never used anything to stop, apart from willpower”
Conversely, other participants identified their lack of willpower and the requirement for assistance.
“Some people have got good willpower and that’s how they give up smoking and it’s cold turkey. Cause their willpower’s strong, mine isn’t. I need something like an aid to give me a hand not to do it [smoking]. Those patches are like an aid.”
A common notion amongst both continued and ceased smokers, was that ceasing smoking is up to the individual, and some were not willing to accept help from external resources such as Quit Line.
“The stubbornness came in, I wouldn’t want to use Quit Line, I thought I don’t need anyone to help me, I can do this myself.”
However, a number of participants were able to identify the helpful nature of the education and motivation given by the healthcare professionals who formed part of their treating team, which overlaps with the teachable moment of a cancer diagnosis.
“If we do this operation, we’re really going to need you to give up smoking, and that sort of stuck in my head.”
3. Psychosocial environment
The role of each patient’s psychosocial environment was an integral component of a patient’s ability to successfully maintain abstinence. The participants home environment was a major element impacting upon cessation. Being unemployed or not able to work after treatment was identified as another barrier to achieving smoking cessation. One participant with a strong cultural background mentioned the prominent role that their supportive family had played in encouraging smoking cessation.
“They gave me a stern talking, and usually it’s the other way around. But this time they all sat me down - me son, my girls, my wife. They had no intention of not having me here, so they told me there and then, no more smoking”
However, residing with other smokers was an issue identified by some continued smokers as a barrier to cessation. One participant recalled living with their sister and how this impacted upon their return to smoking after the completion of treatment.
“She [patient’s sister] buys rollies and gets me to roll them for her and keep them in a tin and I take a few”
For similar reasons, social isolation was identified as a facilitator to cessation for some patients. These participants were able to identify the facilitatory role of living by themselves with no temptations to smoke. Rurality and spending prolonged periods of time away from their usual place of residence, was a factor that was identified as both a facilitator and a barrier, depending upon the individual. Some patients commented that being away from home for treatment facilitated their smoking cessation, as they were removed from the environment in which their bad habits had been ingrained.
“For me, I’d suggest that it helped [living away from home]. Once again, I go back to that environment, where I was smoking…. So, when you remove yourself from that particular environment and you don’t bring cigarettes into your new environment it’s quite easy to go along with the flow as such and don’t smoke.”
Conversely, others noted that the stress of being away from home made them return to smoking.
“Yeah that, I didn’t like it, being away from home. Yeah it probably made me start again [smoking], I think”
Some participants also described the role that their depression played in a return to smoking, as well as the isolation associated with returning to a rural location after the completion of treatment.
“So, after that [treatment] I still smoked. Everything went downhill, maybe because I did have a bit of bloody depression. Maybe it was because I couldn’t get close enough to talk to people here”
4. Relationship with alcohol and marijuana
The relationship of alcohol and marijuana use with tobacco smoking and how these behaviours are intrinsically linked was a common theme identified. The majority of patients who continued to smoke were still either consuming alcohol in large quantities or smoking marijuana.
“It’s all part and parcel because I’m a chronic alcoholic, and you smoke you drink, you drink you smoke”
However, some participants identified that removing the association between alcohol and smoking allowed them to achieve abstinence.
“Sitting there with a glass of wine without a cigarette, I thought, I’m not enjoying this, so I stopped having a glass of wine at 5 o’clock. I removed the temptation”
Some participants who had ceased tobacco smoking identified that they were using marijuana as a substitute for their nicotine use.
“I can’t have a cigarette, I’ll have a cone [marijuana] instead”
Concerningly, the commencement of marijuana smoking after treatment completion was identified as a trigger for tobacco relapse in some patients.
“Well I’ve noticed that I am putting the tobacco in with the marijuana, the reason I done that is that the bloody thing won’t stay alight without tobacco in it.”
Many patients were not able to identify any negative health issues associated with marijuana smoking and perceived it to have minimal effect on their risk of cancer when compared with nicotine.
“Weed [marijuana] would be a lot better than smoking tobacco. You know, it hasn’t got the chemicals in it from being treated through the plant in the factory where they put these chemicals in it”
5. Health knowledge and beliefs of smoking and cancer
This theme encompassed patient’s health knowledge and beliefs surrounding the role of smoking in cancer, smoking cessation and the effects of continued smoking. Most participants with HNC were able to identify that smoking played a role in the formation of their cancer and the harmful effects of continued smoking after their diagnosis. Some patients acknowledged that smoking played a role but identified other factors that they believed may have also contributed to their cancer, such as chemicals from fruit and vegetables or the ‘underground mines’. One continued smoker identified that they were more concerned regarding the harmful effects of their occupational exposure than their cigarette smoking.
“I’m more worried about it coming back [the cancer] when I go back using these chemicals [at the underground mines].”
Prior knowledge of addiction and smoking cessation through occupational interventions was demonstrated as a facilitator for some patients. There were two participants (both ceased smokers) who had prior education regarding addictions and withdrawal. Both of these patients stated the role that this had in allowing them to successfully quit.
“We have a tobacco free day [at work] and one of the things I did learn during that time was craving only lasts a minute so if you can keep your fingers busy and drink some water or some mints or something for that minute, once that minute is up that’s it, it’s done and dusted. So, I had that education behind me as well”