Smoking And Mental Health After Lung Cancer Diagnosis
Overview
This study investigated the emotional well-being, stigma experiences, and their connection to smoking history in individuals diagnosed with lung cancer. Analyzing data from 539 participants across various geographic locations from November 2019 to July 2022, the study utilized validated survey tools to assess demographics, smoking history, stigma types, and emotional functioning (measured by the EORTC QLQ-C30 Emotional Functioning Scale).
The results revealed that individuals diagnosed with lung cancer faced significant distress, compounded by the stigma associated with the disease. Various types of lung cancer stigma were linked to decreased emotional functioning, impacting factors such as depression, anxiety, stress, and irritability. Participants with a history of current or former smoking reported higher levels of both internalized and perceived stigma. Notably, constrained disclosure of the lung cancer diagnosis was prevalent, associated with reduced emotional functioning, but not specifically tied to a smoking history.
Crucially, smoking status itself did not correlate with diminished emotional functioning, emphasizing the prominent role of stigma in contributing to distress. The study concluded that all forms of lung cancer stigma were linked to clinically significant reductions in emotional functioning, irrespective of smoking history. The findings underscore the importance of addressing stigma in the psychosocial care of individuals diagnosed with lung cancer.
Introduction
Lung cancer, a leading cause of global cancer-related deaths, poses significant challenges, with a 5-year survival rate of only 22%. Those diagnosed with lung cancer experience heightened distress compared to other cancers, often compounded by lung cancer stigma. Approximately 95% of individuals with lung cancer encounter some form of stigma, with perceptions worsening over time. Originating from the association with smoking, lung cancer stigma has evolved, impacting emotional well-being and quality of life.
Erving Goffman’s 1963 work laid the foundation for understanding stigma, defining it as signs exposing moral status. Chapple, in 2004 linked stigma and lung cancer, categorizing it as “enacted” or “felt.” Subsequent research unveiled the profound societal, interpersonal, and personal repercussions of lung cancer stigma, affecting emotional functioning and treatment-seeking behaviors.
Stigma manifests through discrimination, stereotyping, and differential medical treatment. Its effects include increased rates of depression, isolation, and a significant impact on quality of life. Webb et al.’s 2018 scoping review highlighted the evolving nature of lung cancer stigma, and Hamann et al. introduced the Lung Cancer Stigma Inventory (LCSI), assessing perceived stigma, internalized stigma, and constrained disclosure.
While limited research has explored the direct relationship between smoking and lung cancer stigma, Williamson’s 2018 study associated internalized stigma with smoking history. This present study utilizes real-world data from a disease registry to delve into the associations between smoking, stigma, and emotional functioning among lung cancer patients, contributing valuable insights to this relatively unexplored area.
Methods
The study focused on participants from the Lung Cancer Registry, a comprehensive platform collecting data on lung cancer experiences. The sample, gathered until July 15, 2022, included 2584 participants with complete smoking history and stigma-related responses. The registry, initiated in 2016, conducts baseline and longitudinal surveys, with updates every three months. Stigma questions were integrated from the Lung Cancer Stigma Inventory, employing a 5-level scale. Smoking history inquiries followed the NCI Cancer Patient Tobacco Use Questionnaire.
Survey responses between November 21, 2019, and July 15, 2022, were considered. Stigma indicators were dichotomized (“Not at all” versus any other level), simplifying modeling. Smoking history dichotomized participants into those with no smoking history and those with a history, irrespective of current or former smoking. Age, sex, geographic region, and time from initial survey participation were explored for associations with stigma.
Multivariable logistic regression models assessed the relationship between smoking status, demographics, and stigma. Ordered logistic regression models were used for sensitivity analyses, considering the ordered nature of stigma responses. Emotional Functioning Scale scores from the EORTC QLQ-C30 were examined in association with stigma, both as a continuous variable and dichotomized using a clinically relevant threshold. Tests for interactions evaluated potential effect modifications.
This rigorous analysis aimed to unravel the intricate connections between smoking, stigma, and emotional functioning in individuals diagnosed with lung cancer, utilizing a wealth of real-world data from the Lung Cancer Registry.
Results
The study involved 539 participants with comprehensive data on stigma, constrained disclosure, smoking history, emotional functioning, and demographics. The sample exhibited diverse geographic representation, including international participants. Approximately 50% reported a smoking history, with higher prevalence among older individuals and lower rates in those with stage IV non-small cell lung cancer. Participants with smoking history displayed increased internalized and perceived stigma but not constrained disclosure.
The analysis demonstrated a noteworthy association between stigma and reduced emotional functioning, measured by the Emotional Functioning (EF) Scale of the QLQ-C30. Those reporting any level of internalized, perceived, or constrained disclosure stigma were more likely to score below the threshold for clinical importance. Participants with smoking history showed higher levels of internalized and perceived stigma but not constrained disclosure. Emotional functioning scores consistently decreased with escalating levels of stigma.
Multivariable models affirmed that a smoking history was independently linked to higher internalized and perceived stigma. Individuals over 70 years had a reduced likelihood of all types of stigma. Time from the initial survey submission correlated with decreased likelihood of constrained disclosure. Sensitivity analyses confirmed these associations using ordered logistic regression models. Notably, smoking status was not directly associated with reduced emotional functioning scores, indicating that stigma does not mediate this relationship.
This study provides robust evidence linking smoking history, stigma, and emotional functioning in lung cancer patients. The findings emphasize the pervasive impact of stigma on emotional well-being, with smoking history playing a role in shaping stigma experiences.
Conclusion
This study, leveraging data from an international registry, delves into the intricate relationship between lung cancer stigma and patient-reported health-related quality of life, providing valuable insights into the emotional well-being of over 500 individuals diagnosed with lung cancer. By employing the EORTC QLQ-C30 Emotional Function subscale, the research discerns a noteworthy correlation between different dimensions of lung cancer stigma (namely perceived, internalized, and constrained disclosure) and a consequential decrease in Emotional Function. The study goes beyond a simplistic examination, considering a spectrum of emotional factors such as anxiety, depression, irritability, and stress, which collectively contribute to the observed distress experienced by individuals with lung cancer.
Within the context of smoking history, the study identifies discernible trends aligning with expectations in the lung cancer population. Older individuals and those diagnosed with small cell lung cancer exhibit a higher likelihood of having a smoking history, reflecting historical patterns of smoking prevalence. The research reaffirms existing evidence linking smoking history to internalized and perceived stigma. Intriguingly, participants over the age of 70 demonstrate a reduced likelihood of experiencing all types of stigma, possibly indicating the normalization of smoking during earlier periods when anti-tobacco campaigns were less prevalent.
Despite the association between smoking history and various dimensions of stigma, the study unveils a nuanced finding: no direct association emerges between smoking history and emotional functioning. Instead, the primary driver of emotional distress is identified as the guilt and blame associated with lung cancer stigma. This underscores the complex interplay of psychological factors in shaping the emotional experiences of individuals facing a lung cancer diagnosis.
A notable revelation from the study is the prevalence of constrained disclosure, where individuals opt to withhold their lung cancer diagnosis from others. Strikingly, this behavior is associated with reduced emotional functioning, including heightened anxiety and depression. Importantly, this association holds true regardless of smoking history, shedding light on the specific subtype of stigma related to disclosure practices.
The study emphasizes the need for healthcare providers to recognize the profound impact of lung cancer stigma on the emotional well-being of patients. It underscores that individuals, irrespective of their smoking status, may grapple with stigma, influencing their treatment adherence and overall quality of life. The research advocates for targeted interventions, such as empathic communication training for healthcare providers and acceptance and commitment therapy for those experiencing internalized stigma. Additionally, the study suggests that interventions may need to be tailored to address the distinct challenges posed by constrained disclosure, indicating a potential gap in current psychosocial care approaches.
Acknowledging its limitations, including potential biases in the online registry data and overrepresentation of certain demographic groups, the study serves as a significant contribution to the body of literature on lung cancer stigma. It calls for a comprehensive, interdisciplinary approach to interventions across the entire lung cancer continuum, recognizing and addressing the diverse subtypes of stigma that individuals may encounter during their cancer journey.
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