Background
According to the World Health Organization (WHO), smoking is responsible for eight million deaths every year [1]. WHO projects that smoking prevalence in the Middle East will only decrease slightly, from 33.3% in 2020 to 31% in 2025. This is the smallest decline among all WHO regions [1]. Studies show that about 64% of cancer survivors continue to smoke after their cancer diagnosis, as presented in several studies [2, 3, 4].
Smoke Carcinogens
Most tobacco-related illnesses and deaths are caused by inhaling the toxic smoke from combustion cigarettes (CC) that reaches the lungs. Conventional cigarette smoke contains approximately 7,000 chemicals, of which about 100 are harmful or potentially harmful. According to the IARC monographs, the effects of tobacco smoke on health are directly related to the dose consumed and the duration of use. Eleven known human carcinogens, such as 2-Naphthylamine and Benzene, are present in cigarette smoke, along with many other chemicals classified as probable or possible carcinogens. Studies show a dose–response relationship between cigarette smoke content and the risk of lung cancer [5].
Let go or risk the end?
Quitting smoking is one of the most effective ways to reduce the risk of cancer. Numerous studies support this. A study by Jha et al. (2013) in the New England Journal of Medicine found that quitting smoking before age 40 reduces the risk of dying from smoking-related diseases by about 90%. The risk of lung cancer specifically drops significantly after quitting, with a 50% reduction in risk within 10 years of cessation. The longer a person remains smoke-free, the more the risk decreases [6]. Several studies provide strong evidence that quitting smoking can significantly improve both quality of life and life expectancy for cancer patients [6, 7].
However, in the Gulf Cooperation Council (GCC) countries, smoking cessation programs show varying success rates, often influenced by cultural, social, and healthcare factors. Challenges include limited resources, a lack of trained healthcare professionals, and social acceptance of smoking. Even with targeted interventions, smoking cessation rates among cancer patients remain low, often due to high nicotine dependence, the stress of dealing with a cancer diagnosis, and the belief that quitting might not significantly improve their prognosis [8].
Do Nicotine Replacement Therapies (NRTs) Cause Cancer?
Studies evaluating smoking cessation interventions, including NRTs for cancer patients, have found that while NRTs are effective and safe—with a quit rate of about 15% at six months—adherence is often an issue. Patients struggle to use NRTs consistently due to side effects of cancer treatments and the psychological burden of their diagnosis [9].
A Cochrane review concluded that NRTs are effective and safe, with no evidence suggesting nicotine itself is carcinogenic. Higher doses of NRTs, such as 21 mg/24-hour nicotine patches, can be safely used to manage high levels of nicotine dependence, especially in heavier smokers. Combining multiple forms of NRTs, such as a patch with gum or lozenges, can also improve quit rates [10].
Global health organizations, including the U.S. FDA, WHO, CDC, and Public Health England, recognize that while nicotine is addictive, it is not the primary cause of cancer associated with smoking. The harmful effects of smoking are largely due to high-dose exposure to toxic substances in tobacco smoke, such as polycyclic aromatic hydrocarbons.
A 2023 Cochrane analysis found that nicotine e-cigarettes, varenicline, and cytisine are currently the most effective options for helping smokers quit long-term (at least six months without smoking). This is followed by using two forms of NRTs simultaneously, such as a nicotine patch with gum, lozenges, or nasal sprays [11].
Can More Be Done to Improve the Quality of Life of Cancer Patients Who Continue to Smoke?
Improving the quality of life for cancer patients who continue to smoke requires a multifaceted approach that addresses both their physical and psychological needs. Here are strategies to complement—not replace—evidence-based smoking cessation methods:
Harm Reduction: While quitting smoking is the ultimate goal, harm reduction strategies can help reduce the negative impact of smoking. This includes switching to less harmful alternatives like e-cigarettes, heated tobacco products, snus, or nicotine pouches, which can lower exposure to harmful chemicals. More studies are needed to assess the effectiveness of snus, nicotine pouches, and heated tobacco products as cessation interventions. The U.S. FDA has granted "modified risk tobacco product" status to some oral and heated tobacco products based on scientific evidence [12]. Real-world evidence, including reductions in cigarette smoking in Sweden and Japan, supports the use of these products [13]. While long-term studies on the effects of switching to Tobacco Harm Reduction (THR) products are still lacking, biomarker studies indicate potential reductions in risks for cancers, respiratory, and heart diseases [14, 15, 16, 17].
Comprehensive Support Programs and Psychological and Emotional Support: Offering access to support programs that include counseling, behavioral therapy, and support groups can help patients manage stress and cope with their diagnosis. These programs can also offer tailored advice on smoking reduction and cessation.
Nutritional and Physical Health: Providing nutritional counseling and encouraging physical activity can improve overall health and well-being. Proper nutrition and exercise can help mitigate some of the negative effects of smoking and cancer treatment.
Education and Communication: Educating patients about the benefits of reducing or quitting smoking, even if they are not ready to quit completely, can motivate positive changes. Clear communication from healthcare providers about the impact of smoking on treatment outcomes is crucial.
References
- Park, E. R. (2012). A smoking cessation intervention for thoracic surgery and oncology clinics: a pilot trial. Journal of Thoracic Oncology, 6(6), 1059-1065.
- Stead, L. F. (2012). Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews, (11).
- Lindson N. . Pharmacological and electronic cigarette interventions for smoking cessation in adults: component network metaanalyses. Cochrane Database of Systematic Reviews 2023, Issue 9.
- US Food and Drug Administration. Modified risk granted orders. (Current as of 3/16/2023.) https://www.fda.gov/tobaccoproducts/advertising-and-promotion/modified-riskgranted-orders.
- Fagerstrom K. Can alternative nicotine products put the final nail in the smoking coffin? Harm Reduction Journal 2022;19:131.
- Azzopardi D, Assessment of biomarkers of exposure and potential harm, and physiological and subjective health measures in exclusive users of nicotine pouches and current, former and never smokers. Biomarkers. 28(1):118– 129.
- Yach D, Applications of biomarkers of exposure and biological effects in users of new generation tobacco and nicotine products: Tentative proposals. Drug Testing and Analysis. 2023;15(10):1127-1132.
- Lüdicke F, Effects of switching to a heat-not-burn tobacco product on biologically relevant biomarkers to assess a candidate modified risk tobacco product: A randomized trial. Cancer Epidemiology, Biomarkers and Prevention. 2019;28(11): 1934-1943.
- World Health Organization [Internet]. WHO global report on trends in tobacco smoking 2000-2025. third edition. (Accessed on: September 2023). Available at: WHO global report on trends in prevalence of tobacco use 2000-2025, fourth edition.
- World Health Organization. WHO report on the global tobacco epidemic 2021: addressing new and emerging products, 2021.
- Bellizzi KM, Health behaviors of cancer survivors: examining opportunities for cancer control intervention. J Clin Oncol. 2005, 23 (34): 8884-8893.
- Eakin EG, Health behaviors of cancer survivors: data from an Australian population-based survey. Cancer Causes Control. 2007, 18 (8): 881-894.
- Hawkins NA, Health-related behavior change after cancer: results of the American cancer society's studies of cancer survivors (SCS). J Cancer Surviv. 2010, 4 (1): 20-32.
- International Agency for Research on Cancer. (2004). IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Volume 83: Tobacco Smoke and Involuntary Smoking. Lyon, France: World Health Organization, International Agency for Research on Cancer.
- Jha, P. (2013). 21st-Century Hazards of Smoking and Benefits of Cessation in the United States. New England Journal of Medicine, 368(4), 341-350.
- Warren, G. W. (2013). Smoking at diagnosis and survival in cancer patients. International Journal of Cancer, 132(2), 401-410.
- Parsons, A.(2010). Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: Systematic review of observational studies with meta-analysis. BMJ, 340, b5569.
