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Original Investigation
January 2018

Association Between Head and Neck Squamous Cell Carcinoma Survival, Smoking at Diagnosis, and Marital Status

Author Affiliations
  • 1Saint Louis University Cancer Center, St Louis, Missouri
  • 2Department of Otolaryngology–Head and Neck Surgery, Saint Louis University School of Medicine, St Louis, Missouri
  • 3Department of Epidemiology, Saint Louis University College of Public Health and Social Justice, St Louis, Missouri
  • 4Saint Louis University Center for Outcomes Research, St Louis, Missouri
  • 5Saint Louis University School of Medicine, St Louis, Missouri
  • 6Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
JAMA Otolaryngol Head Neck Surg. 2018;144(1):43-50. doi:10.1001/jamaoto.2017.1880
Key Points

Questions  Is there an association between smoking status at diagnosis and head and neck squamous cell carcinoma (HNSCC) survival? Are married patients with HNSCC more likely to be nonsmokers than smokers?

Findings  In this retrospective cohort study of 463 confirmed cases of HNSCC, patients who were smokers at the time of diagnosis had lower survival than nonsmokers. In addition, smokers were more likely to be unmarried.

Meaning  Smoking at the time of HNSCC diagnosis is associated with lower survival than nonsmoking; married individuals are more likely to be nonsmokers.


Importance  While the adverse association between smoking and head and neck squamous cell carcinoma (HNSCC) survival has been well described, there are also inconclusive studies and those that report no significant changes in HNSCC survival and overall mortality due to smoking. There is also a lack of studies investigating the association of marital status on smoking status at diagnosis for patients with HNSCC.

Objective  To examine the association between patient smoking status at HNSCC diagnosis and survival and the association between marital status and smoking in these patients.

Design, Setting, and Participants  This retrospective cohort study was conducted by querying the Saint Louis University Hospital Tumor Registry for adults with a diagnosis of HNSCC and treated at the university academic medical center between 1997 and 2012; 463 confirmed cases were analyzed.

Main Outcomes and Measures  Cox proportional hazards regression analysis was used to evaluate association of survival with smoking status at diagnosis and covariates. A multivariate logistic regression model was used to assess whether marital status was associated with smoking at diagnosis adjusting for covariates.

Results  Of the 463 total patients (338 men, 125 women), 92 (19.9%) were aged 18 to 49 years; 233 (50.3%) were aged 50 to 65 years; and 138 (29.8%) were older than 65 years. Overall, 56.2% of patients were smokers at diagnosis (n = 260); 49.6% were married (n = 228); and the mortality rate was 54.9% (254 died). A majority of patients were white (81.0%; n = 375). Smokers at diagnosis were more likely to be younger (ie, <65 years), unmarried, and to drink alcohol. We found a statistically significant difference in median survival time between smokers (89 months; 95% CI, 65-123 months) and nonsmokers at diagnosis (208 months; 95% CI, 129-235 months). In the adjusted Cox proportional hazards model, patients who were smokers at diagnosis were almost twice as likely to die during the study period as nonsmokers (hazard ratio, 1.98; 95% CI, 1.42-2.77). In the multivariate logistic regression analysis, unmarried patients were 76% more likely to use tobacco than married patients (adjusted odds ratio, 1.76; 95% CI, 1.08-2.84).

Conclusions and Relevance  Smokers were almost twice as likely as nonsmokers to die during the study period. We also found that those who were married were less likely to be smokers at diagnosis. Our study suggests that individualized cancer care should incorporate social support and management of cancer risk behaviors.