With a view toward the development of smoking cessation interventions for cancer patients in Russia, this study examined differences between cancer patients who smoke and cancer patients who had quit smoking and examined differences between cancer patients who intend or do not intend to quit smoking. The complexities and challenges of cancer treatment and the negative attitudes associated with tobacco use among cancer patients [27
], along with potential cultural differences between the USA and Russia, indicate the need to explore correlates of smoking behavior in this population instead of simply targeting this population with existing behavioral smoking cessation interventions. Below, we highlight the main findings from this study, the study limitations, and the directions for future research in this area.
First, as suggested by a previous study [18
], smoking among cancer patients in Russia represents a serious public health problem. In the present study, almost one half of patients with a smoking history that were surveyed reported continued tobacco use. This rate is somewhat lower than reported in our previous study with Russian cancer patients [18
] but still greatly exceeds the figure of about one third that is thought to represent the general smoking prevalence rate among US cancer patients [27
]. Moreover, a third of Russian cancer patients who continue to smoke indicated in this study that they have no intention of quitting smoking. This rate is far greater than studies conducted with US cancer patients who smoke [23
]. Overall, these data replicate our earlier findings and underscore the high rate of tobacco use and low rate of intention to quit smoking among Russian cancer patients [18
]. Further, these results highlight that smoking cessation interventions are critically needed for this subgroup of smokers but that interventions may need to be specifically designed to promote motivation to quit smoking. For instance, motivational interviewing, which has been shown to be effective among numerous clinical populations, may be a useful therapeutic approach for Russian cancer patients [39
Second, the present analyses revealed three variables that, controlling for numerous other predictors, differentiated between current and former smokers and patients who intend or do not intend to quit smoking. First, patients who continue to smoke report significantly higher levels of cravings to smoke for positive reinforcement, compared with former smokers. That is to say, that patients who continue to smoke persist in their endorsement, to a significantly greater extent, of the anticipation of pleasure from smoking, compared to patients who have been able to quit smoking. While this is the first time this form of nicotine craving has been associated with smoking behavior among cancer patients, this result converges with the general literature ascertained with US smokers on craving and smoking behavior [40
]. But, this result suggests that craving for positive reinforcement (vs. craving for negative reinforcement) plays a larger role in continued smoking among Russian cancer patients. Therefore, interventions for Russian cancer patients who continue to smoke may need to consider procedures for addressing this unique aspect of craving in order to help patients quit smoking. Two components may be necessary to address this aspect of craving in order to promote abstinence. Pharmacotherapy, including nicotine replacement therapy and varenicline, help smokers quit by mitigating abstinence-induced cravings [41
], so these medications would be expected to be an important part of helping Russian cancer patients to quit via craving reduction. But, behavioral interventions are also critical for addressing craving. In particular, cognitive strategies such as positive self-talk, understanding the time course of craving, and relaxation techniques and behavioral strategies such as developing activities to distract from craving or substitute for the perceived benefits of smoking have been found to be effective at reducing craving and preventing smoking behavior [40
Second, patients with greater intentions to quit smoking exhibited higher levels of perceived risk of the adverse health effects from smoking. This result converges with our previous study with Russian cancer patients [18
] and with a longitudinal study of American cancer patients [2
]. The consistency of this link between perceived risk and smoking behavior among cancer patients further strengthens the rationale for smoking cessation interventions to target this psychological process with cancer patients in order to promote smoking cessation. Cancer patients in Russia are likely unaware of the growing literature from the USA and Europe showing that continued smoking following a cancer diagnosis diminishes treatment efficacy, increases the risk for a recurrence or a second-primary tumor, and worsens quality of life and, as such, educational programs to enhance Russian cancer patient awareness of the health benefits of cessation among cancer patients are likely critical to increase motivation to quit and actual cessation [38
]. Such an intervention could be integrated into formal smoking cessation treatment programs, delivered in conjunction with pharmacotherapy, or conveyed via self-help smoking cessation manuals or brochures.
Lastly, as with risk perceptions, patients who reported a greater sense of self-efficacy (i.e., self-confidence) to quit smoking exhibited a greater intention to quit smoking. Again, this result replicates our previous finding with Russian cancer patients [18
] and converges with data collected from US cancer patients [23
] and with non-cancer patients [20
]. Smoking cessation interventions for Russian cancer patients should utilize techniques to strengthen patient self-efficacy to quit smoking in order to promote cessation. A recent review summarized various methods for promoting self-efficacy in the context of nicotine dependence that have been studied [43
]. The goal of the intervention approach is the same: to develop within the smoker the firm conviction that they possess the ability to quit smoking. Self-help material with descriptions of previous patients who have successfully quit smoking can help build confidence. Brief advice to divide the process of cessation into smaller, more achievable components, may also help facilitate self-efficacy. More structured, multi-session interventions may offer the best chance to help the smoker develop self-efficacy since, in such a setting, the smoker can work with the counselor to devise and implement strategies to quit smoking and avoid relapse, reflect on their achievements, refine, replace, or strengthen the cessation plan, witness periods of abstinence, and experience the emerging confidence that accompanies incremental yet meaningful accomplishments.
The results from this study, however, should be viewed with consideration of study limitations. The study was cross-sectional and the analyses were correlational; as such, no causal interpretations are warranted from these data. In addition, patient reports of smoking status were not biochemically verified in this study. This may have led to an under-reporting of tobacco use and, compared with our previous study with Russian cancer patients, the rate of smoking reported here was lower (48% vs. 66%; [18
]). Likewise, our simple categorical measure of intention to quit may not have captured the complexity of motivation to quit smoking. Further, the present study was conducted at a single institution in Moscow, used measures that have not been widely used in the Russian Federation, used certain measures that were different from past studies with US cancer patients, involved patients with tobacco-related cancers, and used a sample that was predominantly male. Thus, future studies designed to identify correlates of tobacco use and intention to quit smoking among Russian cancer patients should utilize a longitudinal design, use biochemical verification procedures, use standardized measures for constructs from US studies with cancer patients, utilize additional recruitment sites, and include a more heterogeneous sample of patients in terms of tumor site and gender in order to enhance generalizability of results to cancer patients in general.
Nevertheless, the present study is only the second study to attempt to address issues related to the smoking behavior of Russian cancer patients in hopes of stimulating efforts to develop smoking cessation interventions for this sub-group of smokers. The results of this study provide further evidence that there is a critical need for smoking cessation clinical interventions for cancer patients in Russia. Further, these findings, coupled with our previous studies of Russian cancer patients [18
] and American cancer patients [2
], identify several important targets for smoking cessation interventions. In addition to pharmacotherapy to help manage the physical dimension of nicotine dependence and abstinence-induced craving, behavioral treatments for Russian cancer patients should target self-efficacy beliefs, perceptions of risk, and the use of nicotine for positive reinforcement to address the psychological dimension of nicotine dependence. The development and formal testing of this intervention approach, based on data accumulated from the target population, is needed in hopes of reducing the substantial public health problem of continued tobacco use by Russian cancer patients.