Journal of Pediatric Psychology, Vol. 26, No. 2, 2001, pp. 117-121
© 2001 Society of Pediatric Psychology
Brief Report |
Predictors of Intentions to Use Tobacco Among Adolescent Survivors of Cancer
1 St. Jude Children's Research Hospital, 2 University of Tennessee College of Medicine, 3 University of Memphis
All correspondence should be sent to Vida L. Tyc, Division of Behavioral Medicine, St. Jude Children's Research Hospital, 332 N. Lauderdale, Memphis, Tennessee 38105-2794. E-mail: vida.tyc{at}stjude.org .
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Abstract |
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Objective: To examine the relationship between knowledge of tobacco-related health risks, perceptions of vulnerability to these health risks, and future intentions to use tobacco in a sample of adolescent survivors of cancer.
Methods: Written self-report questionnaires were administered to 46 survivors, 10-18 years of age (61% males, 93.5% Caucasian).
Results: Overall, survivors were generally knowledgeable about tobacco-related health risks, perceived themselves to be vulnerable to these health risks, and reported low future intentions to use tobacco. Regression analyses indicated that demographic factors, treatment-related variables, knowledge, and perceived vulnerability explained 28% of the variance in intentions scores, F(6, 39) = 2.52, p <.05. Age and knowledge were significant predictors, indicating that older adolescent survivors and those with lower knowledge scores reported greater intentions to use tobacco.
Conclusions: Young survivors will benefit from risk counseling interventions that educate them about their susceptibility to specific tobacco-related health risks secondary to their cancer treatment. Intensive tobacco prevention programs that target older adolescents should be developed.
Key words: cancer survival; survivors; tobacco use; adolescents.
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Introduction |
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Survivors of childhood cancer are a growing population at increased risk, because of their malignancies and related treatment, for late medical and neoplastic complications that decrease their health-related quality of life and increase early mortality (Hudson, Jones, Boyett, Sharp, & Pui, 1997
). Patients previously
treated with cardiopulmonary toxic agents or thoracic radiation therapy may
develop restrictive lung disease and serious pulmonary complications if they
smoke (Shaw, Tweeddale, & Eden,
1989). Tobacco use may also increase the risk of congestive heart
failure and related cardiac problems in survivors treated with anthracyclines
(Lipshultz et al., 1991).
Furthermore, there is an increased risk of second cancers in survivors
(Robison & Mertens, 1993),
and regular tobacco use may increase that risk.
Even though the adverse health consequences of engaging in tobacco use may
be magnified by treatment exposures among survivors of cancer, results from a
limited number of studies show that survivors use tobacco as much as their
peers who have never been treated for cancer
(Haupt et al., 1992;
Hollen & Hobbie, 1996).
Similarly, data from 40 young adult survivors, 18 to 29 years of age, who
participated in a health behavior survey, indicated that 32.5% used tobacco
(Mulhern et al., 1995). These
preliminary findings, in addition to recent findings from a large-scale study
of survivors'smoking habits (Tao et al.,
1998), suggest a trend toward increased tobacco use as patients
reach young adulthood.
Sociodemographic factors and knowledge about tobacco-related health
problems have been found to play a role in initiation of tobacco use among
healthy adolescents (Bruvold,
1993; Moss, Allen, &
Giovino, 1995). Perceived vulnerability (PV) to health risks, a
well-recognized component of current cognitive-motivational models of health
behavior (Weinstein, 1993),
has been examined as a potential predictor of adolescent health behaviors.
Several studies have reported an inverse relationship between adolescents'
perceptions of vulnerability to health risks and the practice of some risky
behaviors (Gerrard, Gibbons, Benthin, &
Hessling, 1996; Gerrard,
Gibbons, & Bushman, 1996), although the specific association
between PV and tobacco use has not been adequately studied. Self-reported
intention to use tobacco in the future has consistently predicted subsequent
smoking onset in healthy adolescents and has been used as a reliable outcome
measure in adolescent smoking research
(Conrad, Flay, & Hill,
1992; Eckhardt, Woodruff, &
Elder, 1994). Whether knowledge, PV, and other sociodemographic
variables influence intentions to use tobacco has not been previously explored
among patients treated for cancer. The purpose of this exploratory study was
to examine the relationship between current knowledge of tobacco-related
health outcomes, PV to tobacco-related health risks, and self-reported
intentions to use tobacco among preadolescent and adolescent survivors of
childhood cancer. We also explore the role of sociodemographic and
treatment-related factors. Identification of factors that can potentially
influence future tobacco use is critical for developing effective smoking
prevention interventions for this vulnerable cohort.
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Method |
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Participants
Forty-six preadolescents and adolescents who were previously treated for cancer at a children's hospital, were currently disease-free, and were 1 to 4 years from completion of all antineoplastic therapy (M = 1.9 ±.84 years), participated in this study. Forty-one percent of the sample was treated for acute lymphocytic leukemia, 24% for Hodgkin's disease, and 35% for other solid tumors, including osteosarcoma and Ewing's sarcoma. Survivors ranged in age from 10-18 years (M = 13.7 ± 2.3 years). Sixty-one percent of the sample was comprised of males, and 59% were from middle to lower socioeconomic (SES) levels (Hollingshead, 1975
),
consistent with institutional referral patterns. The sample consisted of 93.5%
Caucasians and 6.5% African Americans. Forty-one participants were current
nonsmokers, and five were smokers as based on self-report to the question,
"Have you used tobacco in any form in the past month?"
Procedure
Eligible preadolescents and adolescents were recruited during routine
outpatient clinic visits to St. Jude Children's Research Hospital (SJCRH). All
survivors were seen at least annually in clinic, so the sample was not biased
in the direction of those with more medical problems. Survivors were asked if
they were willing to participate in a study that asked about their tobacco use
and beliefs about tobacco use. Survivors were told that their participation
did not depend on their smoking status or reported intentions for future
tobacco use. Signed informed consent according to institutional guidelines was
obtained. All participants were assured that the information they provided
would remain confidential and would not be reported in their medical chart.
Nearly 31% of survivors approached for the study refused to participate.
Primary reasons for declining participation were lack of interest and lack of
time. We suspect that some survivors chose not to participate because they
were smokers or had smoked in the past and did not want to reveal this
information, although this could not be verified without enrollment in the
study. There were no statistical differences between participants and refusers
based on age, gender, or race (ps >.10). All assessments were
conducted by a master's level psychologist in the Behavioral Medicine Clinic
at SJCRH.
Measures
Knowledge (K). The K scale consists of 25 true-false questions
(maximum score = 25) related to the adverse health consequences associated
with tobacco use. Several questions focus on the increased health risks of the
youngster treated for cancer.
Perceived Vulnerability (PV). This scale is composed of eight
items that measure patients' perceptions of their vulnerability to
tobacco-related health risks secondary to cancer treatment (i.e., "If I
use tobacco, I am in more danger of developing health problems than others my
age who were never treated for cancer"). Unlike other measures of PV
used in previous research, this measure is specific to tobacco-related risk
perceptions. Individual responses were rated on a 5-point scale. Total scores
range from 8 to 40, with higher scores on this item representing greater PV to
cancer-related risks. Cronbach's 
of.75 was computed for this scale and
indicates adequate internal reliability.
Intentions (I). The I scale consists of three items that measure
future intentions to use tobacco as rated on a 5-point scale ranging from
"very likely" to "very unlikely" (i.e., "How
likely is it that you will be tempted to use tobacco in the future?").
Total scores can range from 3 to 15, with higher scores representing greater
intentions to use tobacco. Cronbach's of.79 was computed for this
scale and indicates adequate internal reliability.
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Results |
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Means for the tobacco K and PV scores were 20.72 (SD = 2.61) and 32.41 (SD = 5.36), respectively, indicating that our sample of survivors were knowledgeable about tobacco-related health risks and perceived themselves to be vulnerable to these health risks. On the K scale, the majority of participants responded accurately to general tobacco-related health items, but less than 50% of the sample was able to accurately identify specific treatment-related health risks that could be exacerbated by tobacco use (i.e., "Radiation treatment to the chest area can increase the risk of lung cancer"). Significant positive correlations were found between K and PV scores (r =.36, p <.05). Knowledge and smoking status were significantly related to age (r =.31, p <.05; r =.38, p <.01, respectively). There were no significant gender differences on the K (males: M = 20.54, SD = 2.74; females: M = 21.00, SD = 2.45) and PV measures (males: M = 32.50, SD = 5.15; females: M = 32.28, SD = 5.84). The mean total I score was 5.00 (SD = 2.77), indicating that survivors reported low intentions to use tobacco in the future. Higher intentions to use tobacco were significantly associated with decreased knowledge and current tobacco use, respectively (r = -.38, p <.01, and r =.69, p <.01).
To determine variables that relate uniquely to future intentions to use tobacco, we performed a hierarchical regression analysis, with the total I score serving as the criterion variable. Demographic variables and time since completion of treatment were entered into the regression equation first, as these variables represent fixed factors. Race and smoking status were not included in the analysis due to the small number of minority participants and smokers enrolled on the study. Knowledge and PV variables were entered next, as step 2. Results of the regression analyses are summarized in Table I. The final equation including demographic, treatment-related variables, knowledge, and PV explained 28% of the variance in the intention scores, F(6, 39) = 2.52, p <.05. Age and tobacco-related knowledge were significant predictors, indicating that older adolescent survivors and those with lower tobacco knowledge scores reported greater future intentions to smoke.
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Discussion |
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The results of this study indicate that our sample of young survivors of cancer were generally knowledgeable about tobacco-related health risks, had heightened perceptions of their vulnerability to tobacco-related health risks, and reported little intention to use tobacco in the future, as indexed by their total K, PV, and I scores. Whether these outcomes uniquely characterize youngsters previously treated for cancer is not well understood, as differences in knowledge and health perceptions between healthy adolescents and adolescent survivors of cancer have never been directly assessed in the same study. An important feature lacking in this study that would elucidate this issue is a healthy comparison sample. Inclusion of a healthy control group would be necessary to establish whether the outcomes observed in our survivor sample are related to illness-specific factors or are influenced by their cancer experience. Comparison of high-risk survivors to their low-risk peers on variables of interest should be a priority for future investigation.
The low mean total I scores obtained for our sample should not be
interpreted to suggest that survivors are not at risk for tobacco use
but that they would be good candidates for preventive tobacco interventions.
Our finding that older adolescents reported greater intentions to use tobacco
is consistent with findings among healthy adolescents
(Moss et al., 1995). Although
prevention efforts are certainly warranted for young survivors prior to
adolescence and before intentions to smoke are established, our findings
underscore the need for even more intensive prevention approaches targeting
older adolescents. However, low baseline intention scores, characteristic of
this group, may limit one's ability to detect intervention effects for
programs designed to further reduce intention to smoke. Establishing more
stringent patient selection criteria based on baseline intention scores or
developing more sensitive measures of intentions in this patient group should
be carefully considered in future intervention studies.
The finding that knowledge is a significant predictor of intentions to use tobacco suggests that survivors will likely benefit from tobacco counseling that addresses their personal susceptibility to specific health problems secondary to their cancer treatment. An analysis of responses on the K scale suggests that, although survivors are knowledgeable about general tobacco-related health risks, they are less knowledgeable about specific treatment-related toxicities that can be exacerbated by tobacco use. Although the provision of treatment-specific health information related to the adverse health consequences of smoking may not, by itself, be sufficient in preventing smoking onset, it is critical to provide this risk information as a component of an effective intervention program developed for young survivors. The positive relationship observed between knowledge and PV suggests that accurate tobacco-related health perceptions may reflect adequate knowledge about tobacco-related health outcomes.
The finding of high patient PV to tobacco-related health risks is
consistent with our earlier work with young adult survivors of cancer
(Mulhern et al., 1995).
Although the PV component of the health belief model has been shown to have
predictive value for the practice of health behaviors in young adult and
adolescent populations (Gerrard, Gibbons,
& Bushman, 1996;
Weinstein, 1993), this factor
failed to predict smoking intentions in our sample of survivors. This may, in
part, reflect the limited variability on our PV measure, as items tended to be
endorsed in the direction of high PV. Alternatively, this may reflect a sample
selection bias in that those survivors who presented to the outpatient clinic,
and perhaps were more motivated to seek medical treatment (or perceived
themselves to be more vulnerable), participated in the study.
Several limitations should be noted relating to the results of the study.
First, the sample recruited for the study was small, primarily male, and
Caucasian; 41% were from upper SES levels, such that the limited
generalizability of our data should be noted and our findings interpreted with
caution. Second, although efforts were made to ensure confidentiality, we
cannot exclude the possibility that some youngsters may have overreported
their PV to tobacco-related health risks and underreported their intentions to
use tobacco, as our assessment was conducted in a medical setting. Last, other
variables known to predict smoking onset in healthy adolescents, such as
parental, family member, and peer smoking habits
(Wang, Fitzhugh, Westerfield, & Eddy,
1995), were not examined but should be addressed in future
research.
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Acknowledgments |
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This work was supported by the American Lebanese Syrian Associated Charities (ALSAC) and the National Cancer Institute, Cancer Center Support (CORE) grants CA21765 and CA23099.
Received November 22, 1999; revision received March 17, 2000; accepted July 7, 2000
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