Overall, the risk of any second cancer was increased by 3. Most of the increased risk was attributed to 51 second lung cancers with a histological type other than small cell. Subjects irradiated in the chest had a fold increased risk of developing a second lung cancer compared with a 6-fold increased risk among those who were not irradiated. The risk of a second lung cancer varied with smoking status, with no second lung cancers occurring in the small number of subjects who were non-smokers.
The risk of a second lung cancer did not vary significantly by pack-years at the time of small-cell lung cancer diagnosis. The authors also evaluated the combined effects of smoking status and radiation therapy.
Trends over time were similar and not significant for either group. Among those who continued to smoke, the risks were much higher among those treated with chest irradiation and increased significantly over time. The interaction between smoking and chest irradiation was substantial but not statistically significant because of the relatively small number of events. Subjects treated with various forms of combination chemotherapy showed comparable increases in the risk of a second primary tumor 9.
This study clearly demonstrated that continued smoking increased the risk of a second lung cancer in subjects who had been treated for small-cell lung carcinoma.
The increase in risk among persistent smokers could not be explained by the increment in accumulated pack-years. Although the risk was also increased for laryngeal and other smoking-related cancers, it seems that the entire aerodigestive epithelium is at risk.
This study also suggests that there is probably a synergism between chest irradiation and smoking in the development of second lung cancers. Smoking may act as a promoter in tissues with radiation-induced genomic instability. In conclusion, this study demonstrated that the effects of both radiation therapy and chemotherapy on the development of second primary cancers were substantially enhanced in subjects who continued to smoke.
In this section of our review, we evaluated 6 studies. Three were performed in lung cancer subjects and assessed quality of life and performance status. Different questionnaires for the assessment of quality of life were used; therefore, any comparison between the results was difficult. One study of quality of life was performed in subjects with head and neck cancer.
We also reviewed 2 studies in which pain, a major component of quality of life, was assessed in relation to smoking status. Garces et al 29 evaluated whether smoking cessation after lung cancer diagnosis improves quality of life in lung cancer subjects. Cigarette-smoking patterns at the time of lung cancer diagnosis and at follow-up were assessed to determine the impact of cigarette smoking on a subject's quality of life as measured by the Lung Cancer Symptom Scale LCSS.
The LCSS consists of 9 individual items, and the total score is the average of the sum of those 9 individual items. The first 6 items represent measures of the specified lung cancer symptoms, including appetite, fatigue, cough, shortness of breath, hemoptysis, and pain. The remaining 3 items measure general lung cancer symptoms and how the illness affects normal activities and overall quality of life.
The items are ranked on a visual analog scale of 0— mm. A total of 1, subjects with non-small-cell lung cancer and small-cell lung cancer entered the study. The lower quality-of-life scores corresponded to a better quality of life among never-smokers compared with persistent smokers, who had the highest scores and the worst quality of life. Similar trends and findings regarding total LCSS were noted for all 9 individual LCSS items among different categories of never-smokers, ex-smokers, persistent smokers, and abstinent smokers.
This means that persistent smokers had worse appetite, fatigue, cough, shortness of breath, symptomatic distress, effect on activities, and overall quality of life compared with never-smokers, with ex-smokers and abstinent smokers having intermediate adjusted LCSS.
The quality of life in subjects with head and neck cancer has been investigated by Gritz et al. Subjects who were ex-smokers after 1 y of follow-up reported higher quality-of-life scores than subjects who had not stopped smoking. Quality of life in relation to smoking status was evaluated after lung cancer surgery by Balduyck et al.
Quality of life was prospectively recorded at baseline 1 d before surgery and at 1, 3, 6, and 12 months postoperatively using the European Organisation for Research and Treatment of Cancer quality-of-life questionnaires QLQ-C30 and QLQ-LC13 lung cancer-specific.
Non-smokers showed the best postoperative quality-of-life evolution. All quality-of-life domains returned to baseline in the first month after surgery with the exception of physical functioning. Ex-smokers returned to baseline in most quality-of-life domains 1 month after surgery, although they reported functional deficits during the first 3 months, persistent decreases in role functioning at 12 months, and temporary increases in general and thoracic pain the first month.
Compared with the previous subgroups, recent ex-smokers reported longer physical functioning impairment up to 6 months after surgery and an increase in dyspnea at 1 and 3 months postoperatively.
Current smokers reported a persistent decrease in physical and social functional status during the entire follow-up period, as well as general and thoracic pain up to 12 months after surgery. The effect of post-diagnosis smoking cessation on performance status was evaluated in the study of Baser et al 34 in a population of subjects with non-small-cell lung cancer.
Participants were classified as current smokers, never-smokers, and ex-smokers, and performance status was classified according to the criteria of the Eastern Cooperative Oncology Group. Overall survival was assessed in this study, and performance change at 0, 6, and 12 months was calculated. Subjects who had quit smoking maintained a better performance status at 0—6 months odds ratio of 7.
In this study, survival differences between the 2 groups of subjects were not statistically significant, possibly due to the small number of subjects. According to the authors, several factors may contribute to performance status deterioration, including airway inflammation, decreased lung function, and reduced mucociliary clearance due to the irritant effect of cigarette smoke, as well as tobacco-induced COPD exacerbations.
There is also emerging evidence of a unique relationship between recurrent pain and tobacco use in the general population. Smoking has been associated with the occurrence and aggravation of several conditions associated with chronic pain.
Daniel et al 36 tested the cross-sectional association between post-diagnosis smoking status and pain ratings among lung cancer subjects and found that current smokers reported greater pain odds ratio of 1. Ditre et al 37 examined smoking status and pain reporting in greater detail across a wider range of cancer subjects along with the potential benefits of smoking cessation.
Smoking status and cigarette consumption were determined via self-report at baseline assessment. Subjects were classified as never-smokers, ex-smokers, or current smokers. Pain status and pain interference were assessed using the Medical Outcomes Survey Item Short Form, which is a widely used self-report measure of physical and mental well-being.
Pain-related distress was measured using the Memorial Symptom Assessment Scale Short Form, which is a self-report measure of the severity of 32 symptoms commonly experienced by cancer patients. A total of subjects participated in the study. Cancer diagnoses were categorized as breast cancer No differences in pain-related interference were observed between ex-smokers and never-smokers.
There were no differences in the degree to which subjects experienced distress associated with pain in relation to smoking status. There was no significant correlation between pain-related distress and years since quitting. In both current smokers and ex-smokers, analysis revealed no significant correlations between the number of cigarettes smoked per day and pain severity, pain interference, or pain-related stress.
The characteristics of the participants in studies included in this review, measured outcomes, and main results in relation to smoking are presented in Table 3. Most studies were performed in subjects with smoking-related cancers, such as lung, bladder, and head and neck cancer. A common limitation of these studies is that smoking status was not biochemically evaluated, so there may be a potential bias. Many of the studies were observational, with small or moderate sample sizes.
Regarding smoking status, there were no unanimous definitions of ex-smokers and recent or distant ex-smokers. In 3 studies, the impact of smoking on survival in subjects with limited-stage small-cell lung cancer 8 , 15 and early-stage non-small-cell lung cancer 9 , 15 was evaluated.
None of these studies assessed lung cancer-specific survival. The results of 2 studies in limited-stage small-cell lung cancer subjects were conflicting, although even in a study that failed to demonstrate statistically significant improvement on overall survival, subjects who quit smoking experienced a survival benefit. The most important finding in the study involving early-stage non-small-cell lung cancer subjects 9 is the stronger beneficial effect of smoking cessation on overall survival and recurrence-free survival in light smokers compared with heavy smokers and in women.
The results of a study in subjects with oral cancer 11 are important, but limited by the small sample size. The results of studies 12 , 13 involving subjects with non-muscle-invasive bladder cancer with end points of disease-free survival, progression, and overall survival are very interesting. Although cigarette smoking is considered an established risk factor for the development of bladder cancer, 38 there has been no strong evidence on the effects of smoking on bladder cancer prognosis until recently.
Long-term heavy smokers with primary or recurrent urinary bladder cancer had the worst outcomes, a finding that emphasizes the necessity for smoking cessation counseling in urological patients. A study on women with breast cancer 16 reported some important results, but the most striking finding was that smoking affects not only overall mortality but also breast cancer-specific mortality, although this conclusion derived from a small proportion of current smokers.
Evaluation of the dose-response relationship between smoking and outcome was limited by the lack of detailed information about cigarette consumption and smoking status during the follow-up period. The effect of continued smoking or cessation on anti-cancer treatment effectiveness is of major importance. The same authors in a more recent study failed to prove a statistically significant difference in survival, although abstainers and very light smokers had better survival rates than light, moderate, and heavy smokers.
Differences in survival rates with regard to smoking status in subjects with advanced non-small-cell lung cancer under treatment with erlotinib were demonstrated in large randomized clinical trials and are now clear and well-described.
In addition to the results from clinical trials, recent evidence in animal models suggests that nicotine induces resistance to cancer therapy by inhibiting apoptosis in lung cancer cells. These cells were processed with nicotine for 24 h, followed by cisplatin, etoposide, or both. Nicotine significantly reduced both cisplatin-induced and etoposide-induced apoptosis by modulating the signaling pathway. These effects of nicotine are critically important especially in patients undergoing treatment for lung cancer because activation of the mitochondrial death pathway is one of the most common mechanisms by which many anti-cancer therapeutic agents induce apoptosis in tumor cells.
These findings demonstrate that both active smoking and nicotine supplementation may compromise the response of cancer patients to chemotherapy. Another study in which the authors used an in vitro model to mimic long-term smoking in human lung cancer concluded that lung cancer cells with long-term exposure to cigarette smoke condensates become much more resistant to carboplatin chemotherapy.
The risk of a second primary malignancy is increasing as the number of cancer survivors increases. Although this study also indicates that the treatment of small-cell lung cancer chemoradiotherapy may affect the risk of a second primary lung cancer, this risk seems to be much lower in patients who quit smoking. The last topic addressed in this review is the effect of smoking on quality of life in cancer patients. A common issue in these studies is the different questionnaires used for the assessment of quality of life, complicating the comparison between different studies.
Gritz et al 30 assessed quality of life in subjects with lung cancer both small and non-small cell using the LCSS as described above. The results suggest that persistent smoking after a lung cancer diagnosis reduces quality of life. Despite its limitations, such as selection and survival biases, the results of this study are important and underline the need for smoking cessation interventions after lung cancer diagnosis.
Balduyck et al 31 investigated the effect of smoking on quality of life after surgery for early-stage non-small-cell lung cancer. The authors concluded that smoking cessation is beneficial at any time relative to lung cancer surgery and that subjects who continued to smoke experience a poorer postoperative quality of life.
Pain is a major problem that reduces quality of life in patients with cancer. Data indicate that continued smoking in patients with cancer is associated with increased pain and greater pain-associated functional deterioration. Important limitations of this study are the lack of information about the mechanisms underlying the association between pain and current smoking and the use of cross-sectional data that do not allow the establishment of causal relationships. Despite these limitations, as cancer patients tend to smoke for self-medication, such conclusions could be used to motivate them to quit smoking.
Further studies are needed to obtain more clear results on the association between smoking and pain, which could be used in every patient with cancer. An issue related to quality of life in cancer patients is the effect of smoking on performance status, which has been investigated in non-small-cell lung cancer patients by Bergman et al. This study adds to the existing knowledge that smoking cessation after the diagnosis of lung cancer has a beneficial effect on performance status.
In conclusion, the importance of smoking cessation for all cancer patients, especially those with smoking-related tumors, has been clearly demonstrated in the present review. Although cancer diagnosis and treatment may be teachable moments for smoking cessation, these opportunities may be underestimated by health-care professionals, as most smoking cessation efforts focus on primary prevention.
Health-care providers and patients would benefit from learning about the adverse effects of continued smoking on cancer survival rates, treatment effectiveness, risk for second primary malignancies, and quality of life.
Patients who continue to smoke after cancer diagnosis or treatment should be identified, and smoking cessation interventions for this specific group of smokers and their families should be available and implemented.
NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address. Skip to main content. Review Article Review. Angeliki N Florou. Introduction Tobacco smoking has been clearly linked to the development of lung cancer and also related to increased risk of several other cancers, notably oral, laryngeal, pharyngeal, esophageal, stomach, liver, pancreatic, kidney, bladder, uterine cervix cancer and myeloid leukemia.
Methods In this study, we conducted a comprehensive review of literature discussing the benefits of smoking cessation and the negative effects of continued smoking after cancer diagnosis. Results A large volume of studies were identified from the initial research: 8, papers from the last decade and 11, studies regardless of the date matched at least one of the search terms.
Effect of Continued Smoking on Survival, Mortality, and Disease Progression in Subjects With Cancer The impact of continued smoking during treatment on outcome in limited-stage small-cell lung cancer was investigated in the s in 2 reports.
View this table: View inline View popup Download powerpoint. Table 1. The analyses were adjusted for age, gender, and education. The presence of smokers in the family, in particular the father and relatives different from parents, was a strong predictor of adolescents smoking.
Interestingly, the knowledge of teachers who smoke did not influence the smoking status while seeing teachers who smoke reached the statistical significance. The risk of being current smokers was also predicted by the influence of friends and the feeling of inferiority i. Regarding harmfulness of nicotine, those who are aware of nicotine dangerous action to health seem less likely to be current smokers Table 3.
The present findings show that the lack of knowledge of smoking and second-hand smoking negative effects to health, seeing teachers or having relatives who smoke, being influenced by friends and by the feeling of inferiority are strong predictors of youth smoking. In particular, the strongest predictor seems to be the lack of knowledge of smoking and second-hand smoking effects on health while the influence of significant others follows.
Our data on the knowledge of health risk of smoking find support in the literature. Several studies have documented positive effects, for instance, of the truth campaign [ 19 ]. Moreover, earlier studies showed that among young people exposure to truth is associated with an increase in anti-tobacco attitudes and beliefs [ 20 ].
Relatively few studies have focused on the knowledge about, attitudes toward, and tolerance of second-hand smoking among college students and young individuals [ 21 ]. Even less studies have evaluated the relationship between such a knowledge and smoking. In the general population, never smokers seem to be more likely to acknowledge the health risks of second-hand smoking compared with smokers [ 22 ].
Thus, the present results could work as a spin off in this field of research. Seeing teachers who smoke is a widely documented predictor of early use of tobacco [ 14 , 15 ]. Interestingly, knowing teachers who smoke does not influence adolescent smoking status; once again, significant adults seem to exert substantial influence on adolescent behaviour through modelling with their own smoking behaviour [ 8 ]. Similarly, having relatives who smoke is a predictor of adolescents smoking, consistently with the literature [ 5 , 8 , 11 — 13 , 17 , 18 ].
We found that father, but not mother, smoking status has an effect. This result agrees with some authors [ 12 , 17 ] but not with others [ 13 ]. However, it is noteworthy to note that not every study made the distinction between father and mother smoking status [ 18 ]. The influence of friends has been largely documented: having friends who smoke increases the likelihood of smoking while having friends who do not smoke reduces such a risk [ 5 , 8 , 11 , 13 ].
Although it is not completely clear which variable between peers and significant adults has the strongest influence on adolescent smoking, according to the present findings significant adults have a relatively stronger effect than friends. However, the literature on this issue is extremely heterogeneous probably because of differences among countries [ 14 ], for instance, significant adults have a stronger role than peers in China [ 13 ] and in Pakistan [ 11 ].
It is the other way around. The possible role of cultural difference should be considered since it is already relevant for college student motives to quit [ 24 ]. The present study has some limitations. First, a cross-sectional research design was used and causality cannot be determined. Second, the data represent only students in public middle and high schools in Lombardy; national as well as international multi-sites, including public and private schools, data collection might produce more generalizable results.
In addition, some students in schools were not surveyed and some were absent the day of the survey for reasons other than refusal to participate in the study introducing the chance of some non-response bias. Finally, we could not attain biomedical validation of the current smoking status of the respondents altough and no measurements of phase delays in circadian rhythmicity were collected although addiction negatively affects rhythmicity e.
Despite the above limitations, the present research represents an important step ahead to identify the variables to be targeted in prevention programs. Such programs should be addressed to both significant adults and adolescents. In the first case, campaigns should awaken adults that adolescents tend to replicate their behaviour; thus, their smoking is not only a problem for their own health and a disease itself but has dramatic implications on the health of their children and pupils.
In the second case, campaigns should awaken adolescents on the truth of smoking and second-hand smoking harmfulness to health. These latter programs should be addressed to adolescent smokers and nonsmokers as well as to students and non-students in order to mitigate the negative effects of peers influence on smoking.
This would possibly change the vicious circle due to the influence of smoking peers into a virtual circle related to the influence of no smoking peers. Our findings stress the importance of youth smoking research in order to understand the influences, beliefs, and knowledge about smoking among youth and the relationship between these factors and the smoking status.
This will provide a starting point in the development of effective smoking prevention interventions specifically addressed to adolescents. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Received 17 Sep Accepted 30 Oct Published 27 Nov Abstract Tobacco use is dramatically increasing among youth. Introduction Tobacco use is one of the major preventable causes of death in the world. Methods This was a school-based cross-sectional study conducted in 16 educational institutions located in 5 municipalities of Lombardy North Italy. Statistics From the initial sample of 3, subjects we excluded students since they did not provide information on their smoking history.
Results 4. Demographic and Smoking Characteristics Among the 2, students analyzed, 1, were boys Bivariate Analyses In Table 1 we compared smokers and nonsmokers regarding the main sources of possible influences on their smoking status. Table 1. Table 2. Multivariate logistic regression analysis adjusted for age, gender, and education.
Table 3. Table 4. Multivariate logistic regression analysis of all the statistically significant variables, adjusted for age, gender, and education.
View at: Google Scholar R. View at: Google Scholar J. Methods: In this study the literature on adolescent smoking in the U. Limitations in the studies are identified and future research directions are suggested.
Results: In the U. In the South Korean literature, various levels of smoking have not been differentiated.
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