Persistent Tobacco Use After Treatment for Head and Neck Cancer

Importance: Smoking during and after treatment has been linked to increased morbidity and mortality in patients with head and neck squamous cell carcinoma (HNSCC). Posttreatment tobacco use patterns and the appropriate timing for cessation interventions are understudied. Objective: To determine the frequency and patterns of posttreatment smoking cessation in smokers with HNSCC. Design, Setting, and Participants: This prospective cohort study assessed smoking status after a new diagnosis of HNSCC among daily smokers who were treated at a tertiary care center at an academic institution between January 1, 2009, and December 31, 2017. Exposures: Being current daily cigarette smoker at the time of diagnosis of HNSCC and having smoked at least 5 cigarettes per day for at least 5 years. Main Outcomes and Measures: Patients provided data indicating smoking intensity, duration of tobacco use, number of cessation attempts, number of successful cessation days, and symptoms during cessation attempts, as well as demographic and clinical information at the time of diagnosis, as well as smoking and disease status at 6 months, 12 months, 18 months, and 24 months after treatment. Results: Eighty-nine smokers with HNSCC (mean [SD] age at enrollment, 60.1 [9.2] years; 74 [83.1%] male and 15 [16.9%] female; 2 [2.2%] American Indian or Alaska Native, 1 [1.1%] Asian, 3 [3.4%] Black, 71 [79.8%] White, and 12 [13.5%] of unknown race and ethnicity or whose race and ethnicity were not reported) completed 24 months of posttreatment follow-up and were included in the study. Fifty-two patients (58.4%) continued to smoke at 6 months after treatment, 47 patients (52.8%) smoked at 12 months after treatment, 41 patients (46.1%) smoked at 18 months after treatment, and 40 patients (44.9%) smoked at 24 months after treatment. The probability of smoking cessation was highest during the first 6 months after treatment, at 0.36. Mean (SD) number of cigarettes per day (17.8 [9.6] vs 12.4 [10.0], mean difference, 5.1 [95% CI, 0.2 to 10.6]), duration of tobacco use (28.2 [18.1] vs 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] vs 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 vs those who successfully quit. Conclusions and Relevance: The results of this cohort study suggest that a significant proportion of patients with HNSCC who are daily smokers at the time of diagnosis continue to smoke after treatment. Smokers with HNSCC who successfully quit smoking were most likely to do so in the first 6 months after treatment, which could potentially serve as a preferred window for smoking cessation interventions. These data highlight the need for inclusion of aggressive smoking cessation intervention in head and neck cancer care pathways.