Patterns and associations of smoking and electronic cigarette use among survivors of tobacco related and non-tobacco related cancers: A nationally representative cross-sectional analysis

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Introduction

Smoking is the leading preventable cause of cancer and cancer deaths in the US with 40 % of all incident cancers being tobacco-related [ 1 ]. Despite evidence that continued smoking places all cancer survivors at increased risk for worse outcomes, regardless of whether their initial cancer was smoking related, up to 64 % continue to smoke [ 2 ] and 26 % use e-cigarettes [ 3 , 4 ]. Continued smoking is associated with lower survival, higher rates of recurrent disease, an increase in secondary malignancies, poorer response to cancer treatment, and increased treatment-related complications [ 5 , 6 ], ultimately leading to significantly increased costs associated with cancer treatment [ 5 , 7 , 8 ].

In the last decade, electronic cigarettes (e-cigarettes) use has risen among cancer survivors. This increase has been seen among non-smokers and combustible cigarette smokers alike [ 9 ] even though the carcinogenic potential of e-cigarette use is not yet fully understood [ 3 , 9 , 10 ]. Despite being thought of as a safer alternative to traditional tobacco use, e-cigarette use has been linked to several smoking related malignancies including lung, head and neck, and bladder cancer [ 111213 ]. Therefore, their use has become an important concern among cancer providers.

After a cancer diagnosis, survivors of tobacco-related cancers have different patterns of tobacco use and quit rates compared to survivors of non-tobacco related malignancies [ 2 , 14 , 15 ]. Smoking prior to a cancer diagnosis has been shown to be more than 20 % higher among tobacco-related cancer survivors [ 14 , 15 ]. Furthermore, smoking cessation approaches vary significantly where counseling is offered twice as often among tobacco-related cancer survivors while pharmacotherapy is prescribed less frequently to survivors of non-tobacco related cancers [ 15 ]. Patterns of e-cigarette use among cancer survivors have been unclear, however, emerging data suggest an increase in use; the majority who report using e-cigarettes do so to aid in smoking cessation, but with limited success [ 16 , 17 ]. The rise in their use may additionally reflect, in part, a perceived harm reduction approach to switch to potentially lower-risk tobacco products [ 181920 ].

The primary objective of this study is to determine factors associated with continued cigarette and e-cigarette use among tobacco-related and non-tobacco-related cancer survivors. We hypothesize that compared to survivors of non-tobacco related cancers, survivors of tobacco related cancers are less likely to continue to use cigarettes. Additionally, we also hypothesize that survivors of tobacco related cancers are more likely to use e-cigarettes. As a secondary study objective, we sought to assess contemporary patterns of cigarette and e-cigarette use over time. Understanding patterns of use relative to time since diagnosis and cancer type may inform smoking cessation strategies that can be integrated with long-term comprehensive cancer care.