Author ORCID Identifier

https://orcid.org/0000-0002-8845-2794

Semester

Spring

Date of Graduation

2024

Document Type

Dissertation

Degree Type

PhD

College

School of Pharmacy

Department

Pharmaceutical Systems and Policy

Committee Chair

Kimberly Kelly

Committee Co-Chair

Khalid M Kamal

Committee Member

Virginia Scott

Committee Member

Thomas Hogan

Committee Member

Felicity Harper

Abstract

Prostate cancer is the leading cancer in men. Continued tobacco use after prostate cancer diagnosis may affect a patient’s treatment outcomes, quality of life, and mortality. Despite the potential negative outcomes, 10-20% of prostate cancer patients continue to use tobacco after their cancer diagnosis. Considering risks associated with continued tobacco use, there is a lack of evidence-based tobacco cessation strategies to address tobacco cessation specifically in prostate cancer. Given the increasing prevalence of prostate cancer, the ongoing difficulty in tobacco cessation, and the limited evidence-based tobacco cessation interventions in the literature, it is important to prioritize reducing tobacco use in prostate cancer patients.

This dissertation had three specific aims. The first aim was to conduct a systematic review with a meta-analysis to evaluate tobacco use and tobacco cessation interventions among patients and informal caregivers (ICs) for prostate and other cancers (breast, prostate, colorectal, bladder, cervical cancer, and leukemia). The study was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines. Five electronic databases, namely PubMed, Scopus, CINAHL, PsycINFO, and Web of Science, were searched through July 2023, and randomized controlled trials assessing tobacco cessation interventions were identified. A total number of 17 studies were included in the review. Intervention studies included behavioral (n=14), pharmacotherapy (n=2), and a combination (n=1) treatment. Eight studies included a health behavior model, and the mean number of behavior change techniques utilized per study was 5.5. Pooled magnitude of the odds of cessation was positive and significant [OR= 1.2, 95% CI (LL 1.0, UL 1.5)]. Cumulative meta-analysis examined the accumulation of results over time and demonstrated that studies have shown significant improvement in tobacco cessation since 2020. Only two studies included a dyadic approach that involved a caregiver. The results showed that reviewed interventions have the potential of reducing tobacco use and may be beneficial in tobacco cessation in other cancers. Despite the potential of dyadic approaches in cancer, there is a lack of interventions targeting these approaches for tobacco cessation in cancer and thus, a need to further to explore the utility of dyadic interventions.

The second aim was to evaluate intervention preferences among prostate cancer patients and ICs and to guide the development of a tobacco cessation intervention. For this study, we surveyed prostate cancer patients and ICs who were active or former tobacco users, ascertained through oncology and urology practices in Appalachia, a medically-underserved region with access barriers, higher rates of poverty, and lower educational attainment than the US population. This cross-sectional study was guided by the Transtheoretical Model (TTM) and collected information on demographics, cancer distress, tobacco use status, stages of change, and processes of change. A newly developed 9-item scale measured intervention preferences for tobacco cessation. Three open-ended questions explored the reasons for quitting and preferences for intervention components. Multivariate analysis of covariance assessed the association of processes of change and intervention preferences with demographics, stages of change, and role type (patient and IC). A qualitative thematic approach was used to analyze open-ended questions. A total of 141 individuals (129 patients; 12 ICs) participated in the study. Study participants had a mean age of 68.8 (SD=7.7) years. Patients were White (100.0%) and married (62.1%). ICs were female (91.6%), White (100.0%), and married (83.3%). Females, ICs, and former tobacco users showed higher utilization of processes of change. Regarding intervention preferences, participants endorsed education and dyadic support strategies and had a low endorsement of Internet-based and writing interventions. Themes included the importance of education, need for intervention strategies (gradual reduction in tobacco use, reviewing personal motivators, need for cues to quit), need for positive IC support, and interest in open discussions with IC. The results provided a robust understanding of tobacco cessation in prostate cancer patients and ICs and identified strategies employed by former tobacco users for tobacco cessation.

The third aim had two goals: 1. utilize qualitative interviews to expand on the survey results and to develop a pharmacist-delivered tobacco cessation intervention and 2. to evaluate the feasibility, acceptability, and preliminary impact of the developed intervention. Eligible participants were prostate cancer patients with active tobacco use status and their ICs. Each patient was paired with their IC. Qualitative semi-structured interviews built on the results from the second aim and explored participants’ impressions of the proposed intervention for tobacco cessation. Content analysis results were used to further develop and modify the proposed intervention. The modified intervention was assessed for feasibility, acceptability, and preliminary impact. A total of 20 individuals (10 patients, 10 ICs) participated in the qualitative interview. Patients were White (100.0%), married (60.0%), and active tobacco users (100.0%). ICs were female (80%), White (100.0%), married (80%), and non-tobacco users (70.0%). All participants (both patients and ICs) lived in the Appalachian region, and 40.0% were from non-metro (rural) areas. Content analysis identified major codes (continued tobacco use in cancer, difficulty with quitting tobacco, access related issues, intervention strategies,pharmacists’ expertise) that informed intervention development. Five dyads (n=10, 5 patients and 5 ICs) further participated in the intervention’s feasibility. Based on TTM, the 6-week hybrid intervention successfully advanced active tobacco users (n=5) from the contemplation to the action stage. The intervention was rated high for attention (M=5.4, SD=1.1), liking (M=5.5, SD=1.1), comprehension (M=5.1, SD=0.9), and yielding (M=5.8, SD=0.7). Participants were satisfied with the intervention (M=7.1, SD=1.6). The intervention was rated acceptable (M=4.3, SD=0.5) and appropriate (M=4.1, SD=0.5). The intervention successfully moved active tobacco users from the contemplation to action stage. By documenting feasibility, acceptability, and appropriateness, we identified facilitators for tobacco cessation in an underserved community, offering insights for future cessation strategies.

To summarize, the first aim provided insights on the current interventions employed for tobacco cessation in moderate risk cancers. The results showed that dyadic interventions are underutilized for tobacco cessation in cancer and need more recognition. The second aim assessed the intervention preferences and identified patient-centered strategies employed by former and active tobacco users. The identified strategies and processes of change served as the foundation for the development of our pharmacist-delivered tobacco cessation intervention. Information from the first and second aims served as the foundation for the third aim. This aim identified information on continued tobacco use and intervention strategies among prostate cancer patient and IC dyads. The intervention showed the advancement of active tobacco users from the contemplation to the action stage. By demonstrating feasibility, we were able to show that the intervention was well received and has a potential for tobacco cessation among prostate cancer patients and ICs in an underserved community. Despite the extensive use of dyadic interventions in cancer, the utilization of dyadic interventions in the context of tobacco cessation in cancer is still limited. ICs are a largely untapped resource, and future interventions are likely to benefit by expanding their utilization of dyadic interventions. Further, other strategies identified in our results may be utilized and adapted by clinicians in oncology centers to reduce tobacco use in cancer.

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