Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: Tobacco use remains the leading cause of preventable death in the U.S, with smoking being a major modifiable risk factor for lung and head and neck cancers (L/HNC). Tobacco use, specifically combustible cigarettes, and associated spending may exacerbate financial toxicity (FT), however, little is known regarding this relationship and its implication on oncologic outcomes. we explore the association between tobacco use, associated spending, and FT in patients with L/HNC.
Methods: This mixed-methods study was performed from 3/15/24-9/30/24. Participants were eligible if they were 18 years or older, English-speaking, and newly diagnosed with L/HNC. The COmprehensive Score for financial Toxicity [(COST), 11-items scored 0-44, lower scores represent worse FT], USDA six-item food security model [scored 0-6: 0-1 food secure, 2-6 food insecure] and smoking-induced deprivation tools were used to assess psychosocial, material, and behavioral components of FT. Semi-structured interviews were audio-recorded, transcribed, and analyzed using a conventional content analysis approach until thematic saturation was reached.
Results: Eighteen participants were enrolled (mean [range] age, 61 [45–79]; 10 [55%] male; 13 [72%] White). Median COST score was 25 (range: 8—39). Diagnoses included oropharyngeal (n=5), laryngeal (n=3), skin (n=2), and thyroid Hurthle cell carcinoma (n=1), non-small cell lung cancer (n=6), and concurrent non-small cell and small cell lung cancer (n=1). Half of the study participants continue to smoke after their cancer diagnosis. On average, participants spent $207 (SD: 160; range: 5—400) per month on cigarettes, despite 28% reporting an annual income below $9,999. Additionally, 22% indicated being unable to afford household items in the past month due to cigarette purchasing. Most (72%) reported high food security, while 28% faced marginal, low or very low food security. Eight key themes emerged from qualitative interviews, including behavioral dependency, facilitators of smoking cessation, financial toxicity of cancer treatment, nicotine dependence, opportunity costs of cancer treatment, opportunity costs of cigarette purchasing, opportunity costs of smoking, and uncertainty about cancer treatment costs. Consistent with established frameworks, nicotine dependence was the primary barrier to smoking cessation, with many describing smoking as a behavioral dependency linked to specific activities (e.g., eating) or emotional states (e.g., stress). Conversely, life-threatening medical emergencies or a new cancer diagnosis prompted participants to quit or reduce smoking. When prompted on the financial impact of smoking, opportunity costs of cigarette purchasing were described as changes in spending habits and lifestyles to afford cigarette purchasing. Patients expressed concerns or anxiety regarding their cancer treatment due to the uncertainty surrounding the costs of their treatment.
Conclusion: Despite a cancer diagnosis, many patients continue to smoke, often prioritizing cigarette purchases over essential household items and compromising financial security. Although patients are aware of the health risks and financial burden of smoking, nicotine and behavioral dependency remain significant barriers to tobacco cessation. We identify new cancer diagnoses as a key touchpoint where patients contemplate smoking cessation, underscoring the need for incorporating timely targeted interventions that address both the physiological and behavioral components of tobacco dependence. We further highlight the importance of cost-related discussions in oncologic care.