Critical Appraisal Checklist and Worksheet

Seung Hee Choi, PhD, RN

Roxane R. Chan, PhD, RN

Rebecca H. Lehto, PhD, RN

Relationships Between Smoking Status and Psychological Distress, Optimism, and Health Environment Perceptions at Time of Diagnosis of Actual or Suspected Lung Cancer

K E Y W O R D S

Anxiety

Lung neoplasms

Optimism

Perception

Smoking

Background: While much research and practice resources have addressed

smoking cessation among cancer patients, less emphasis has been placed on

personal psychological and environment factors associated with smoking at the time

of diagnosis. Objective: The aim of this study was to examine differences in

psychological distress, optimism, and perceptions of the health environment/illness

experience based on smoking status in patients with current, former, and no smoking

history with newly diagnosed suspected or actual lung cancer. Methods: Data

were derived from a descriptive study of 52 patients (34 men and 18 women

aged 37-83 years) undergoing diagnostic evaluation for actual or suspected lung

cancer. Descriptive statistics were used to characterize data. Analysis of variance,

#2, and Spearman correlation tests were used to determine relationships among

main study variables (smoking status, anxiety, worry, perceived cognitive

functioning, optimistic outlook, health environment/illness experience perceptions).

Results: Current smoking status was associated with higher psychological distress

(anxiety and worry) among patients facing a new suspected or actual cancer

diagnosis. Conclusions: The study was able to provide important information

relative to smoking status and psychological distress at the time of diagnosis of

suspected or actual lung cancer. Findings demonstrate needs for assessment and

156 n Cancer NursingA, Vol. 42, No. 2, 2019 Choi et al

Copyright B 2018 Wolters Kluwer Health, Inc. All rights reserved.

Author Affiliations: College of Nursing, Michigan State University, East Lansing. This study was funded by a National Institute of Nursing Research grant

(1 F31 NR07695-01A1). The authors have no conflicts of interest to disclose.

Correspondence: Seung Hee Choi, PhD, RN, College of Nursing, Michigan State University, 1355 Bogue St, Room #C250, East Lansing, MI 48824 ([email protected]).

Accepted for publication October 31, 2017. DOI: 10.1097/NCC.0000000000000579

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

targeted interventions to reduce psychological distress and to promote long-term

adaptation in patients smoking at time of diagnosis. Implications for

Practice: Nurses are positioned to provide support and resources for cancer

patients. It is critical that smoking cessation interventions also address nicotine

craving, emotion regulation, and adaptive coping skills.

L ung cancer is the leading cause of cancer death and the second most common cancer in incidence for both men and women in the United States.

1 Smoking exposure is

the primary environmental factor responsible for the incidence of lung cancer.

1 A diagnosis of actual or suspected lung cancer

is a serious life-threatening stressor that may be compounded by its association with smoking status. Patients who are active smokers have the added stressor of smoking cessation at the time of a potentially life-threatening diagnosis of lung cancer.

2 Although

many patients with newly diagnosed suspected or actual lung cancer are current smokers,

3,4 little research has examined rela-

tionships between smoking status at diagnosis in relation to psy- chological distress and personalized perceptions relative to the healthcare environment and illness experience. Evaluating patients" perceptions about the illness context and level of psychological distress in relation to smoking status is important because it may impact adaptation over time. Therefore, the purpose of this study was to examine psychological distress and perceptions of healthcare environment and illness experience in relation to smok- ing status (current, former, and never smokers) and smoking intensity at the time of a suspected or new lung cancer diagnosis. The inquiry examines presence of an optimistic outlook related to these factors and discusses implications of these findings rela- tive to the role of the nurse as a patient advocate.

n Background

Patients who receive a new diagnosis of suspected or actual lung cancer face multiple cognitive and emotional challenges.

5 Given

the disease is associated with smoking, patients may feel respon- sible if they perceive the diagnosis is related to smoking behav- iors.

6 Furthermore, patients may perceive stigma from healthcare

providers, friends, and family that contributes to lowered per- ceptions of support.

6 Problems relative to smoking behaviors

and emotional vulnerability have been recognized in other cancer and medical conditions. For example, smoking continuation and relapse were associated with heightened psychological distress (anxiety, depressive symptoms, worries about potential recur- rence) in patients with oral and oropharyngeal malignancy.

7

Studies have found relationships between smoking behavior and anxiety problems.

8,9 Individuals with higher anxiety sensi-

tivity, a fear and avoidance of anxiety symptoms, are more moti- vated to smoke and to relapse following quit attempts.

10 These

connections between anxiety, especially anxiety sensitivity, and smoking relapse may be attributed to a dysfunction of the neuro- logical gating system, which then leads to overestimation of mild breathing discomfort that has been shown to be corrected

through administration of nicotine through smoking or patch administration.

11,12

The cognitive processing, particularly the types of content that is processed, associated with a life-threatening illness is critical to adjustment to the disease.

13 Worry, involuntary aver-

sive cognitions about anticipated threats and concerns, is com- mon and associated with anxiety in patients with newly diagnosed life-threatening illnesses such as cancer.

14 Worry has been shown

to correlate with a particular disruption in the variability of one"s breathing pattern, a disruption that is corrected through spon- taneous and on-demand sighs similar to breaths used during cigarette smoking.

15,16 Environmental factors that heighten worry

such as unanticipated stipulations to quit smoking, the need for forthcoming treatments associated with potential adverse effects, and personal life adjustments also may compromise perceived cognitive effectiveness for patients with newly diagnosed lung cancer.

5 Realistic worry that occurs with effective cognitive func-

tion and contributes to lowered negative affect may be adaptive in the face of serious stressors and/or threats where cognitive resources are targeted toward the problem so that effective strat- egies for coping can be utilized. However, in risk reduction re- search such as cancer screening, results are mixed in the role of worry in motivating positive health behavior.

17

Patients" perceptions of the healthcare environment, whether positive or negative, impact illness adaptation. Patients with cancer strongly desire active participation in their treatment in- formation about options and expectations and desire time from healthcare professionals for support and communication.

18

However, healthcare professional interactions have been shown to trigger the most concerns over the postdiagnosis period con- tributing to negative adaptation in patients with cancer.

19

A growing literature has examined factors associated with positive adaptation to cancer.

13,14,20 Dispositional optimism is

a stable personality tendency to expect positive outcomes from life events.

21 In the face of a life-threatening diagnosis of can-

cer, patients who are realistically optimistic might reflect on positive goal-oriented or problem-solving aspects as opposed to aversive, negative self-deprecating thoughts.

20 On the other hand,

patients may unrealistically assume their risk of adverse health consequences is lowered despite evidence to the contrary.

22 In

this regard, optimistic individuals may underestimate risk and potential negative outcomes associated with smoking behaviors.

22

Self-regulation research and theory articulate mechanisms for understanding how illness perceptions impact behavior and adaptation in the face of life-shattering health threats.

23 In this

regard, the context or environment is critical to recognizing how patients build mental frameworks that guide their interpretation, decision making, and coping strategies in the face of cancer.

Smoking Status Among Lung Cancer Cancer NursingA, Vol. 42, No. 2, 2019 n 157

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Smoking conduct may be backed by beliefs that the behavior serves a self-regulation role for managing negative affect states and stress.

24

While much research and practice resources have addressed smoking cessation among cancer patients, less emphasis has been placed on personal psychological and environment factors associated with smoking at the time of diagnosis. Therefore, the purpose of this study was to examine (1) differences in psy- chological distress and perceptions of the health environment/ illness experience between patients who are current, former, and never smokers; (2) differences in these associations by smoking intensity; and (3) whether optimism influences these associa- tions in relation to smoking status at diagnosis among newly diagnosed patients with suspected or actual lung cancer. We operationalize psychological distress as evidence of heightened anxiety, worry, and lowered perceived cognitive effectiveness.

n Methods

Design

Data were derived from a study of patients undergoing diag- nostic evaluation and treatment for actual or suspected lung cancer at a Midwestern university comprehensive cancer center and a Veterans Administration health system.

Sample and Setting

The convenience sample was composed of 52 patients who were assessed during the pretreatment period in relation to psycho- logical parameters, perceptions about their illness experience, and the health environment. Inclusion criteria included patients who were (a) 21 years or older and (b) diagnosed as having actual or suspected nonYsmall cell lung cancer. Exclusion criteria included the following: (a) a known history of cancer other than the suspected lung cancer, (b) documented cognitive or psy- chiatric disorder (eg, dementia, schizophrenia, major affective disorder), (c) history of a debilitating medical disorder such as advanced cardiac or respiratory disease, and (d) current psy- choactive medication that would impede study participation.

Procedures

Full institutional review board approval was received from the respective university and participating medical center sites. Eli- gible volunteers were approached by the study researcher during scheduled preoperative or clinic visits where patients and phy- sicians discussed diagnostic test results and future treatment (eg, surgery). The researcher explained the purpose, requirements, risks, benefits, and rights, including the right to withdraw from participation at any time before written informed consent was obtained. If participants agreed to participate in the study, they completed the surveys in a private consulting room. At the time of the survey, 44% of the patients had only suspicious test find- ings and did not yet have a confirmed diagnosis. The diag- nosis was confirmed, and the disease stage was determined

after surgery. All measures were administered using a standard set of instructions.

Measures

Demographic information included age, marital status, race/ ethnicity, educational level, occupation, and employment status. Health history information including smoking status was obtained from the computerized medical access systems. Smoking status was categorized as current, former, and no previous history. Smoking pack-years were calculated by multiplying the number of cigarettes smoked per day and the number of years smoked.

Psychological Distress

Anxiety was measured by the validated Spielberger"s State-Trait Anxiety Inventory.

25Y27 Consisting of 2 separate 20-item scales,

participants were asked to rate current (state) and general (trait) perceptions about how they feel on a 1- to 4-point scale, from ‘‘not at all’’ to ‘‘very much so’’ (range, 20-80).

25 In this study,

the Cronbach"s ! coefficients for the state and trait anxiety scale were .94 and .87, respectively.

Worry was evaluated with measures of both general (non- specific) and cancer-related worry. The Penn State Worry Ques- tionnaire (PSWQ), a 16-item self-report instrument, was used to measure the frequency and intensity of general worry.

28,29

The PSWQ is scored on a 5-point Likert scale with response options of 1 (not at all typical) to 5 (very typical), with a summed composite score (range, 16Y80). In this study, the Cronbach"s ! coefficient for the PSWQ was .90. Cancer-related worry was measured with a 3-item Cancer-Related Worry Questionnaire to evaluate perceived worry about cancer, cancer treatment, and the impact of cancer-related worry on daily functioning using a 5-point Likert scale (range, 3Y15).30,31 The Cronbach"s ! coef- ficient was .85.

Perceived effectiveness in cognitive functioning was eval- uated with the validated Attentional Function Index (AFI) con- sisting of 3 essential domains of effective action, interpersonal effectiveness, and attentional lapses.

32,33 The AFI consists of 16

linear analog scales that are labeled with polar opposite phrases at each end (‘‘not at all,’’ ‘‘extremely well’’; range, 0Y100).32 The Cronbach"s ! coefficient for the current study was .87.

Health Environment Perceptions

A 7-item survey was developed to obtain information about the patient"s perceived illness experiences in relation to the health- care environment, such as perceptions about treatment partic- ipation, time taken by doctors and nurses to listen to concerns, and opportunity to make choices and ask questions relative to treatment and scheduling of appointments.

5 Participants were

asked to rate on a 5-point scale from 1=‘‘not at all’’ to 5=‘‘always’’ or ‘‘a lot’’ statements related to current experiences with the health- care environment (range, 7-35). Higher scores indicated stronger agreement with statements. The Cronbach"s ! coefficient was .81.

The 10-item Life Orientation TestYRevised (LOT-R) was used to measure optimistic outlook.

34 The LOT-R consists of

158 n Cancer NursingA, Vol. 42, No. 2, 2019 Choi et al

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10 Likert-scale items (0 = strongly disagree, 4 = strongly agree) that reflect expectations of positive versus negative life expe- riences. Only 6 items of the LOT-R are used in scoring the in- strument (4 items are filler), so the scale has a range of 0 to 24. The Cronbach"s ! coefficient was .84.

Statistical Analysis

All statistical procedures were performed using the SAS pro- gram. Descriptive statistics were computed on all variables. To examine differences in distress and perceptions about the health environment/illness experience between patients who were current, former, and never smokers, one-way analysis of var- iance (ANOVA) test for continuous variables and #2 or Fisher exact test for categorical variables were performed. Assumptions of ANOVA test were examined, and none of them were vio- lated. To examine distress and perceptions about the health environment/illness experience in relation to optimistic outlook, Spearman correlation test was conducted. Statistical significance was determined at the level of .05.

n Results

The study sample was composed of 52 adults aged 37 to 83 years who were being evaluated for possible thoracic surgery following a new diagnosis of suspected or confirmed stage nonY small cell lung cancer at 2 Midwestern hospitals (Table 1). The majority of patients were either current (n = 12 [23%]) or for- mer (n = 37 [71%]) smokers at diagnosis with a mean 49.79 pack-years. Most participants were white (94%), male (65%), and currently married (69%). Half of the patients had a high school education or less and were retired. Most patients had either stage I or II disease (75%), reflecting their eligibility to be evaluated for potential curative surgical resection. More than half of the patients (56%) had a confirmed cancer diagnosis prior to surgery.

Table 2 shows descriptive results for the major study vari- ables. The mean state anxiety score was 43.75T14.25, demon- strating that the patients in general were experiencing anxiety. Trait anxiety ranged from 20 to 67, with the mean of 37.73 (SD, 10.44). The mean PSWQ score indicated lower levels of worry, yet there were patients in the sample with general worry comparable to psychiatric populations (range, 20-75). On the Cancer-Related Worry Questionnaire, the mean score of 11.06 was reflective of generally moderate to high levels of cancer- related worry, with scores ranging from the lowest to the highest possible score.

The AFI scores reflect low to only moderate levels of per- ceived cognitive effectiveness. Such findings suggest that pa- tients in general were experiencing symptoms of cognitive fatigue, challenges with emotion regulation, and difficulties with focus and concentration in relation to completing common tasks asso- ciated with daily life. Importantly, the range of scores of the Illness Experience Questionnaire was 13 to 35, suggesting per- ceived satisfactory interactions with the healthcare environment in general.

Scores on the optimism scale (LOT-R) ranged from 6 to 24, with the mean of 15.90 (SD, 3.7). Analysis of sex differences in the major study variables showed a trend of females having higher psychological stress (higher anxiety and worry) and higher opti- mism, albeit mostly not significant except trait anxiety (t =j2.10, P = .041).

Differences in Distress and Illness Experience Based on Smoking Status. Compared with either patients who were former or never smokers, patients who currently smoked tended to report higher anxiety (both state and trait) and worry (both general and cancer related) and lower levels of perceived effec- tiveness in cognitive function, positive perceptions about the health environment/illness experience, and optimistic outlook (Table 3). Most correlations, however, were not significant except cancer-related worry (F = 3.61, P = .034), where current smoking status was associated with the highest levels of cancer-related worry. Currently smoking patients reported the least positive perceptions about their health environment and illness experience, although this was not statistically significant (F = 2.56, P = .087).

To further examine these associations in relation to smoking intensity (pack-years), one-way ANOVAs were conducted (Table 3).

Table 1 & Demographic and Health Characteristics (N = 52)

Mean (SD) Frequency (%)

Age, y 64.08 (11.62)

Race/ethnicity White 49 (94.23) African American 3 (5.77)

Gender

Female 18 (34.62) Male 34 (65.38)

Marital status

Married 36 (69.23) Widowed 10 (19.23) Divorced 6 (11.54)

Education, y 12.77 (1.98) Employment status

Employed 18 (34.73)

Retired 25 (51.02) Unemployed 6 (12.24)

Children Has children 48 (92.31)

No children 4 (7.69) Smoking status

Current smoking 12 (23.08)

Quit smoking 37 (71.15) Never smoking 3 (5.77)

Pack-years 49.79 (30.75)

Stage I 18 (34.62) II 22 (42.31) III/IV 12 (23.08)

Preoperative diagnosis Confirmed 29 (55.77) Suspected 23 (44.23)

Smoking Status Among Lung Cancer Cancer NursingA, Vol. 42, No. 2, 2019 n 159

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Compared with either never smokers or patients with less than 20 pack-years, patients with 20 pack-years or greater showed higher anxiety (state and trait) and worry (general and cancer related) and less positive perceptions of their health environment/ illness experience, perceived effectiveness in cognitive function, and optimistic outlook, although these associations were not significant with most variables. The only significant difference in relation to smoking intensity existed in cancer-related worry (F = 3.29, P = .046).

Associations of Distress and Illness Perception With Life Orientation. While greater optimistic outlook tended to be associated with decreased levels of anxiety (state) and worry (gen- eral and cancer related) and with increased perceived effectiveness in cognitive function, these findings were not statistically signifi- cant. However, there were significant inverse relationships between optimistic outlook and trait anxiety (>=j0.36, P=.01) and posi- tive perceptions of the healthcare environment/illness experience (>= 0.49, PG.001).

To further examine differences in these relationships relative to smoking status, Spearman correlations were repeatedly tested with smokers only (n=48), current smokers only (n=12), or former smokers only (n = 37). Although the directions of the relationships did not significantly change in most cases, effect sizes were larger mostly when the analyses included only current smokers (Table 4).

n Discussion

The study examined differences in psychological distress and perceptions of the health environment/illness experience among

current smokers, former smokers, and never smokers who had newly diagnosed suspected or actual nonYsmall cell lung cancer. The majority of the patients had stopped smoking by the time of assessment, and only 6% of the sample had no smoking history.

Overall anxiety levels in this sample were similar to those of general medical and surgical patients or college students under stressful examination conditions.

26 While the comparative find-

ings depending on smoking status were not significant, the 12 patients who were currently smoking had clinically significant levels of state anxiety. As shown in the literature,

35,36 increases

in trait anxiety were significantly associated with decreased opti- mistic outlook. Importantly, cancer-related worry was in the highest range among current smokers.

Perceptions of effective cognitive function were the lowest among current smokers, consistent with previous studies.

37,38

Underlying mechanisms of such findings are not clear, yet dec- rements may be associated with increased levels of cortisol re- sulting from high levels of psychological distress (eg, anxiety and worry) existing among current smokers at diagnosis.

38 Percep-

tions of effective cognitive function were significantly and posi- tively related to optimistic outlook, similar to other studies where dispositional optimism was related to improved perceived cog- nitive function.

39 Our patients showed similar optimistic levels

as reported in the general population. 21

These findings demon- strate the importance of assessment and management of psycho- logical distress (anxiety and worry). It is critical that smoking cessation interventions address psychological distress including training in emotion regulation and physiological nicotine crav- ing management to promote cessation efforts and reduce relapse in lung cancer patients. Cognitive behavior therapies and mindfulness- based interventions that focus on adaptive coping skills and re- lieving stress might be beneficial.

40,41

Limitations

The present study has limitations that must be considered. First, the study is limited by the small convenience sample that was lacking in both ethnic and racial diversity. The small sample size, especially never smokers, may provide low statistical power, leading to a reduced chance to detect a true effect and low re- producibility of results.

42 However, such findings are reflective

of patients with lung cancer more generally where the majority

Table 3 & Bivariate Association in Relation to Smoking Status and Smoking Intensity (N = 52) Smoking Status Smoking Intensity

Never Smokers

(n = 3), Mean

Former smokers

(n = 37), Mean

Current Smokers

(n = 12), Mean P

Never Smokers

(n = 3), Mean

G20 Pack- Years (n = 11),

Mean

Q20 Pack- Years (n = 38),

Mean P

Anxiety (state) 33.33 43.57 46.92 .339 33.33 37.27 46.45 .070

Anxiety (trait) 36.00 36.70 41.33 .400 36.00 33.45 39.11 .279 General worry 36.67 40.70 42.83 .746 36.67 37.45 42.24 .462 Cancer worry 6.00 11.14 12.08 .034 6.00 11.09 11.45 .046

Attentional function 72.17 60.35 56.39 .264 72.17 62.95 58.35 .243 Illness experience 32.33 29.24 25.92 .087 32.33 29.64 28.08 .348 Life orientation 16.33 16.35 14.42 .341 16.33 16.45 15.71 .850

Table 2 & Major Study Variables Mean (SD) Range

Anxiety (state) 43.75 (14.25) 20.0Y77.0 Anxiety (trait) 37.73 (10.44) 20.0Y67.0 General worry 40.96 (12.83) 20.0Y75.0 Cancer worry 11.06 (3.70) 3.0Y15.0 Attentional function 60.12 (14.97) 28.56Y91.63 Health environment/illness

experience 28.65 (5.45) 13.0Y35.0

Life orientation 15.90 (3.97) 6.0-24.0

160 n Cancer NursingA, Vol. 42, No. 2, 2019 Choi et al

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is either current or former smokers. 43Y45

Moreover, the aim of this study was to explore relationships between psychological and environment factors and smoking status; thus, studies with larger sample sizes are needed before findings are generalizable. The findings were reliant on self-reported smoking status. Given the social stigma associated with smoking, self-reported smoking status without biochemical verification could introduce misclas- sification of current smokers. Furthermore, the study was cross- sectional in nature. Therefore, it is unable to provide information on causal relationships as do longitudinal studies. The study was unable to provide information about anxiety sensitivity in this group of patients, which could better demarcate markers of emotional vulnerability in smoking patients.

10

Nursing Implications

Nurses are cognizant of the need to provide smoking cessation counseling and resources for patients with newly diagnosed lung cancer. Patients who successfully stop smoking following a cancer diagnosis have better clinical outcomes, such as decreased fatigue and shortness of breath, increased functional activity level and quality of life, less treatment toxicity, as well as better sur- vival.

46Y48 The Surgeon General"s Report ‘‘The Health Conse-

quences of SmokingV50 Years of Progress’’ articulated the essential need for providing cessation interventions to cancer patients.

49,50 A diagnosis of cancer can be a ‘‘teachable moment’’

because many patients are highly motivated to quit smoking as the benefits of quitting are evident.

51,52 However, smoking

cessation may be cognitively and emotionally overwhelming to patients who smoke to help manage stress in the face of a life- threatening stressor.

2 Given that unsuccessful quit attempts may

increase psychological difficulties and subsequently affect can- cer adaptation negatively, interventions beyond smoking cessa- tion counseling (eg, assessing contributing factors of continuing smoking) may be needed for patients with a smoking-related cancer diagnosis.

7

Less attention has been played toward promoting optimistic outlook for patients with lung cancer. Although the benefits of smoking cessation have been well established, fatalistic view toward health consequences is prevalent among patients with

lung cancer, which may contribute to relapse. 52

Identifying re- sources and helping patients to recognize positive, realistic aspects of their lives are important. The study was able to provide im- portant information relative to smoking status and psychological distress at the time of diagnosis of suspected or actual lung cancer.

Research Implications

More research is needed to develop understanding of patient and disease factors that impact smoking and smoking cessation. Further research in both lung cancer groups and other cancer populations is also needed to clarify factors associated with persistent smoking following diagnosis. Studies aimed at better understanding strategies that would help vulnerable subgroups of patients with high distress to manage the negative effects of managing an addiction coincident with receiving a life- threatening diagnosis are needed. Surprisingly, a recent Cochrane review identified no randomized controlled studies of smoking cessation interventions tailored to lung cancer patients.

53 Psy-

chotherapeutic modalities, such as mindfulness-based cognitive therapy, which address negative perseverant cognitions such as worry with cognitive-behavioral and mindfulness meditation prac- tices, are promising.

54 Such interventions also target the relaxation

response providing somatic quieting for affective activation. It is also imperative that physiological mechanisms that connect breathing patterns with psychological states such as worry, anx- iety, and negative affect are evaluated such as measurement of breathing timing parameters in persons prone to continued smoking or smoking relapse. This knowledge would guide appropriate incorporation of practices such as yoga and qigong breathing practices into mindfulness-based cessation interven- tions that may prevent smoking relapse via relief of interoceptive discomfort to reduce anxiety sensitivity.

55,56 Finally, longitudi-

nal studies that are able to address the impact of smoking on subsequent cancer adaptation are imperative.

n Conclusion

Given the better clinical outcomes for patients who successfully stop smoking following a lung cancer diagnosis, heightening

Table 4 & Associations With Life Orientation (N = 52)a

All Patients (N = 52)

All Smokers (n = 49)

Current Smokers (n = 12)

Former Smokers (n = 37)

Anxiety (state) j0.27 j0.25 j0.34 j0.18

(P = .055) (P = .080) (P = .276) (P = .299) Anxiety (trait) j0.36 j0.33 j0.49 j0.21

(P = .010) (P = .020) (P = .109) (P = .205) General worry j0.16 j0.14 j0.23 j0.06

(P = .247) (P = .345) (P = .472) (P = .721) Cancer worry j0.19 j0.17 j0.33 j0.11

(P = .177) (P = .234) (P = .301) (P = .502) Attentional function 0.19 0.16 0.16 0.18

(P = .177) (P = .258) (P = .622) (P = .281) Health environment/illness experience 0.49 0.47 0.45 0.44

(PG .001) (PG .001) (P = .144) (P = .007)

a Spearman correlation.

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efforts to ensure that cessation is permanent are essential. Cog- nitive behavior therapies incorporating adaptive coping and stress management skills could be options to help manage distress, pro- mote effective cognitive functioning, and promote cessation efforts for smokers diagnosed as having lung cancer. Open discussion and provision of referrals for individual and/or family counseling may be needed to facilitate effective coping with a new diagnosis of lung cancer.

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