A Global Public Health Challenge and its Impact on Mortality

Introduction

1.1 Research Background

Concept of Smoking Tobacco

Tobacco smoking primary includes increased smoking of cigarettes by individuals of all ages. The tobacco smoke act as an addictive substance because it effects to produce dopamine and endorphins along with promotes the release of neurotransmitters in the brain. It causes triggering of heightened emotions and alertness leading the individuals to feel pleasure (World Health Organization, 2018). The use of tobacco for smoking is dated back to 5000 BC when it was used for medical, religious, recreational and other purposes (tobaccofreelife.org, 2021). As per current condition, it is seen that nearly 1.5 trillion cigarettes are smoked each day by the population of the world. It is responsible to be one of the biggest public health issues that have led to the mortality of 8 million people each year around the globe. Nearly 7 million of the mortality is caused by direct use of cigarettes whereas 1.2 million of them are caused due to second-hand smoking radiation and others among the non-smokers (WHO, 2021). In the world, 80% of the tobacco used for smoking are used in the low- and middle-income countries leading the burden to tobacco-related illness the most in those countries. The difference in the type of cigarette been smoked and way they are used vary according to individuals. The variations are unable to be determined through the counting of number of cigarettes been smoked. It is seen that based on the type and way cigarettes are smoked, the exposure of carcinogens and biomarkers in the smoke is determined which is related to the nature of DNA damage and mutation to be developed by the person to face lung cancer (Ringh et al., 2019). For students seeking expert guidance in understanding and addressing tobacco-related health issues, in that case, healthcare dissertation help can provide them with valuable insights and guidance.

Concept of Lung cancer

Lung cancer is the abnormal growth of cells in the lungs which are the organs responsible for supplying oxygen to the body and removing carbon dioxide from the body. The individuals who are addicted to smoking cigarettes are seen to have highest chance of developing lung cancer. The signs and symptoms of lung cancer are extensive coughing and coughing out of blood, weight loss, fatigue, chest pain, pain in the bones, difficulty swallowing and others (Howlader et al., 2020). The study by Waqar and Morgensztern (2017) mentioned that lung cancer typically initiates from the inner lining of the bronchi and other parts of the lungs like alveoli and bronchioles. There are mainly two forms of lung cancer that are non-small cell lung cancer (NSCLS) and small-cell lung cancer (SCLC). The SCLC are present in 10-15% of individuals and it also known as oat cell cancer. It tends to grow in a faster way than the NSCLC due to which most of the diagnosed individual with the type of lung cancer are seen to be diagnosed at late stage (Tsoukalas et al., 2018).

In 80-90% of the individuals, NSCLC is the nature of lung cancer been experiences and they have different subtypes like adenocarcinoma, large cell carcinoma and squamous cell carcinoma. The subtypes mainly initiate from different nature of lung cells and are grouped to be known as NSCLC as their symptoms and treatment are similar (Norum and Nieder, 2018). The adenocarcinoma is the cancer of the lungs that imitate the cells responsible for releasing mucus in the inner lining of the lungs. They are commonest sub-type of NSCLC seen in individuals and is more common in women compared to the men with probability of occurring in the young age compared to older age. Squamous cell carcinoma is development of carcinogenic growth in the squamous cells that are the flat cells present in the inner airway of the lungs. They are often found near the bronchus which is the middle part of the lungs (Shoshan-Barmatz et al., 2017). The large cell (undifferentiated) carcinoma may develop in any part of the lung and tends to grow in a quick and steady manner making it harder to be treated (Norum and Nieder, 2018).

Mechanism of lung carcinogenesis caused due to smoking

The smoking of cigarettes is found to be initiated by individuals at an early stage such as during the teenage or young adult stage before the individuals are able to understand and appreciate the addictive power of smoking tobacco and general health issues to be faced that would led towards their early mortality. The use of cigarettes over the years leads the individuals to get addicted to the habit due to presence of nicotine as the addictive components in the cigarettes smoke (Li et al., 2018). The study by Stading et al., (2021) mention that smoking cigarettes with each puff leads to delivery of mixture of different carcinogenic component along with nicotine in the lungs. Nearly 5000 components are found to be present in cigarettes smoke among which 73 components are found to be carcinogenic (Jasper et al., 2021). However, it is informed that nicotine is chemical compound that is found in plant that is not directly related to cause cancer. This is because nicotine at low doses are used in product provided to individuals in the nicotine replacement therapy (NRT) which gradually replace the affinity and need of the substance in smokers (cancer-code-europe.iarc.fr, 2021). In contrast, the study by Lee et al. (2018) highlighted that nicotine may have a role in promoting cancer. The study though performed on mice mentioned that nicotine present in the e-cigarettes created mutagenic components like O6-methyldeoxyguanosines and γ-hydroxy-1,N2-propano-deoxyguanosines in the bladder, lungs and heart which are responsible for promoting cancer.

In the study by Leuppi‐Taegtmeyer et al., (2021), it is mentioned that most of the carcinogens in cigarette smoke are drug-metabolising enzymes like glutathione S-transferase, cytochromes P450 and UDP-glucuronosyl transferases which are responsible for catalysing them to be converted to water-soluble forms that are easily detoxified and excreted. However, during the process, epoxides or carbocations which are reactive intermediates is seen to be produced and the electrophilic components are found to reach and react with nucleophilic sites present in the DNA like the oxygen or nitrogen atoms of the deoxy-guanosine or other bases of DNA. It results in to form DNA adducts that have a critical role in supporting the carcinogenic process (An et al., 2019). The study by Gào et al., (2019) informs that DNA adducts are responsible for dictating production of DNA repair enzymes which are able to fix damaged DNA. In the study by La Fleur et al., (2019), it is mentioned that unrepaired DNA adducts presence in the body leads to miscoding during DNA replication as they are bypassing the polymerase catalyses the insertion of any wrong DNA base opposite to the adduct. It results in formation of permanent mutation and in case the mutation occurs in KRAS or TP53 that is the tumour suppression gene, it results in initiation of abnormal growth and support cancer development. In the studies of Tang et al., (2016), Xu et al., (2016) and Zhao et al., (2019), it is mentioned that mutation in the genes is caused in the lungs of the smokers such as TP53 and KRAS genes leading them to be prone to experience lung cancer.

The study by Słowikowski et al., (2017) mentioned that constituents in the tobacco smoke such as tobacco-specific nitrosamines and nicotine are seen to develop direct boding with the cellular receptors without any support for metabolic process. It is often seen to activate PKA, Akt and other pathways that have immense contribution towards increased carcinogenic process. In contrast, the study by Hou et al., (2019) mentioned that cigarette smoke contains various compounds which induces inflammation that result in increased pneumocyte proliferation and presence of enhanced tumour promoters, co-carcinogens, gene promoter methylation and inducers of oxidative damage which all has increased contribution towards development of lung cancer. In the study by Ma et al., (2019), it is mentioned that DNA adducts that are present in the smoker lungs responsible for progressing lung cancer are 7-methyl dG, 7-ethyl-dG, O-ethy-dG and others which act as direct ethylating agents from the cigarette smoke to act on mutating DNA.

Carcinogens in cigarettes responsible for Lung cancer

In cigarette smoke, wide number of carcinogens are present among which PAH and NNK are the two key individual carcinogens found to be responsible in robustly inducing rise of lung cancer. The Polycylclic Aromatic Hydrocarbons (PAH) are mainly genotoxic carcinogens that require enzymatic activation for DNA-reactive intermediates like bay region diol epoxides that are carcinogenic as well as mutagenic to react easily with the DNA adducts which are well characterised as miscoded. On the basis of PAH structure, mode of entry and others are seen to vary but they are seen to cause active mutation in the KRAS and TP53 gene specifically (Moorthy et al., 2015). The Nicotine-derived nitrosamine ketone (NNK) like 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and N'-nitrosonornicotine (NNN) are present in the cigarette smoke which are responsible in inducing carcinogenesis within the lungs. They work initially by implication of tumour promotion through activation of β-adrenergic receptors (β-AdrRs) and nicotinic acetylcholine receptors (nAChRs). It leads to downstream activation of parallel pathway of signal transduction which facilitates progression of tumour formation in the lungs (El-Meghawry El-Kenawy et al., 2015). The study by Vu et al., (2016) explained more detailed mechanism of action of NNK in promotion of lung cancer. It mentioned that NNK mechanism of developing lung cancer contains six steps that are reduction of the carbonyl group in the DNA, oxidation of the pyridine nitrogen followed by methylene carbons that are adjacent to N-nitroso nitrogen reaching α-hydroxylation. The other steps include α-hydroxylation of the adjacent methyl carbon of N-nitroso nitrogen followed by dinitrosation and formation of DNA adduct (Vu et al., 2016).

1.2 Aim and Objectives

The aim of the study is to analyse the impact of smoking cigarettes as a risk factor for lung cancer patients.

The objectives of the research are:

To identify characteristics of smoking as risk factor for lung cancer

To evaluate the impact of smoking on causing lung cancer in patients

To analyse the challenges faced by lung cancer patients in cessation of smoking

To recommend strategies to prevent lung cancer among smokers

1.3 Rationale of the Research

In the global condition, lung cancer is referred as the second most common cancer diagnosed among individuals which is mainly caused due to increased smoking. As per 2018, nearly 2 million people globally are found to be suffering from lung cancer among which most of them are active smokers (WRCF, 2018). In Europe, Hungary has the highest rate of lung cancer that is 56.7 per 100,000 population whereas in the UK, it is 32.5 per 100,000 population (WHO, 2021). In the UK, 1 in 15 female and 1 in 13 men are found to be suffering from lung cancer. It is reported that nearly 35,100 deaths are caused by lung cancer in between 2016-2018 and 21% of all cancer reported in the UK is mentioned due to lung cancer (cancerresearchuk.org, 2021). This indicates that lung cancer is a major health issue in the UK as well as globally which is leading many individuals to experience mortality.

The risk of smoking and lung cancer have currently become an issue because smoking is key cause of the issue and the survival rate for lung cancer is low. It is evident 3 in 20 of people diagnosed with lung cancer in the UK are seen to survive 5 years or more whereas 1 in 10 diagnosed cancer individuals live for 10 years or more (cancerresearchuk.org, 2021a). According to world report, the smoking rate by 2030 is going to be 17% of the population which was 21% in 2015 (cancerresearchuk.org, 2021a). This indicates that smoking cessation rate are increasing. However, the cessation of smoking is often seen to be failure in some individual and notable change in the lung cancer control is unable to be reached. Thus, to present a detailed evidence-based fact regarding the way smoking acts as a major risk factor for lung cancer, the current study is been developed.

1.4 Ethical and GDPR Consideration

The permission to execute the study is to be gathered from appropriate university authorities and professional prior to its execution. The ethical consideration is the study is to be managed to ensure no violation of moral values is executed while framing the researcher that may led to lawsuits and cancellation of the study to be used in evidence-based practise (Qamar, 2018). One of the ethical issues faced in narrative systematic review as data from other studies are included. In order to avoid plagiarism, all the facts gathered from existing studies are to be paraphrased and referenced with appropriate authors. This is to ensure each of the data is effectively credited to the researchers who are responsible for identifying and presenting them to be used for further research purpose. The potential studies yet with violated ethical rules are to be avoided from inclusion in the study to ensure ethical consideration. The personal beliefs and thinking of the researchers are to be controlled from influencing results to be presented in the study so that no error in findings are raised out of manipulated presentation of data. The ethical concern of beneficence and nonmaleficence is to be ensured in the study. This is to be developed by ensuring the results presented are beneficial for the public facing the public health issue focused in the research and avoiding any harm to be faced by the target population of the study. Moreover, the presented data is to be reanalysed by additional researchers to ensure they are not manipulated in any way while presentation in the current study.

1.5 Structure of Document

The structure of the document includes presence of introduction and background chapters at the beginning. They are to provide overview regarding the study topic so that effective understand regarding issue being focussed in the study is developed. The chapter is going to inform the rationale of the study along with aim and objectives to execute the research. The next chapter is to be methodology in which the research methods used in framing the study is to be explained. The chapter is significant as it acts as guidance for the researchers performing the current study regarding the way to develop strategies and move to frame the study in successful way. It is also important as it assists the researchers to explain way they are going to develop the study which helps in creating confidence in others who are supporting in execution of the study. The next chapter to be focussed after methodology is the results and findings. In this chapter, detailed information gathered from the analysis of existing articles are to be presented under specified themes so that they are categorically or systematically informed to explain and resolve issue focussed in the study. Thereafter, discussion chapter is to be formulated where facts from the existing articles collected are to be discussed to explain how the related and resolve the raised health problem in the study. Further, the conclusion and recommendation chapter are to be framed to mention summary of the collected data and recommendations to be followed on the basis of the current study. In the end, reflection regarding the learning from the dissertation is to be mentioned.

Chapter 2: Methodology

Research Method

The systematic review is the review with clearly framed research question that implements reproducible methods for selection, identification, and critical analysis of relevant studies that is required for collection and analysis of data from exiting studies included in the review (Mavragani et al., 2018). The systematic review is to be used in framing the research because it ensures use of systematic methods for gathering answers regarding a specific question which is raised in the study. In comparison, meta-analysis is the statistical process for analysis and combination of findings from different similar studies to explain the raised research question (Yli-Huumo et al., 2016). It is also to be used because it reduces the risk of biasness in the study due to effective criteria for selection of studies being followed. The method also allows to maintain transparency in search strategy and replicability of the review (Cruz Rivera et al., 2017). The narrative literature review method is not to be used because does not allow systematic selection of studies which leads to error in presentation of results. Moreover, the method leads to subjective analysis of the facts rather than presenting them in critical way which hinder the progression of the study is quality manner (Batbaatar et al., 2015).

The meta-analysis is not to be used in executing the study because they support careless towards abstracting and summarisation of studies leading to failure in considering the significant covariates. It also supports inclusion of errored studies along with summarisation of homogenous data that disrupts effective presentation of findings and raise chances of duplication of information (Soga et al., 2017). The meta-analysis is also not to be used because it creates hindrance in inclusion of studies that have differences in population, comparatives, intervention and others which limits the scope to presenting wider analysed findings in the study. It leads to overestimation of strength of studies and precise the presentation of results that led to invalid study presentation of findings (Birkhäuer et al., 2017).

PEO Question

A well-defined research question is important because it helps to explain the nature of population and outcome to be expected from the study. Thus, it helps to present the key focus and purpose of the study along with pinpoints the exact facts to be present in the study (Aamir et al., 2018). The PEO framework is to be used in framing the current research question. This is because it would systematically help to identify the target population, exposure to be focused and outcome intended to be gathered through the farmed question. The PICO framework is not been used as there are current no intervention been focused in the study based on which the research question is to be framed. The research question is: What is the impact of smoking cigarettes as risk factor for lung cancer in adults?

PRISMA Framework

The PRISMA framework primarily focuses to report the reviews by evaluating impact of intervention but also is used for the basis of reporting the way systematic review is performed. The PRISMA flowchart informs about the way information is expressed through different phases in the review. It maps the number of recorded articles identified, exclude or included along with the reason for excluding the articles in reaching the exact number of articles to be used in presenting results and findings.

Search Strategy

The research is to be performed by following the electronic search strategy in which electronic platforms are used for gathering information. This is because it is the easiest way of collecting and selecting articles related to the study by use of simple keywords that helps in identifying many potential articles without much effort. It also allows less time to be consumed in selecting related articles and ensure less expenditure (McGowan et al., 2016). Thus, electronic search is to be used as is faster, time-saving and economic way to gathered required articles for the study. The electronic platforms to be used in identifying and gathering information are CINHAL, EBSCO and Medline.

The CINHAL is to be used because it is one of the most authentic nursing and healthcare platform where wide number of scientific research articles are present with well-defined study format along with impeccable presentation of result related to focussed topic (CINHAL, 2021). The Medline is to be used because it is national library for collected information of medical journals and articles with bibliographic references to select wide variety of required information for any medical topic (nlm.nih.gov, 2020). The EBSCO is to be used as it contains wide number of databases, e-journals, e-books and others regarding various topic to help identifying any required data for accomplishing any study topic (ebsco.com, 2020). The keywords are essential to be identify as they are main words present in the research on which most of the focus is present as they define the purpose of the study. The keywords for the current study are “Lung cancer”, “Lung carcinoma”, “smoking cigarettes”, “tobacco smoke” and others. The use of Boolean operators AND and OR is to be made to compile the keywords in formulating a meaningful research. On the basis of the electronic platform used, the keywords are to be slightly modified to ensure identifying best information for the study.

Inclusion and Exclusion criteria

The inclusion and exclusion criteria in the study mention the characters which are required to be present and avoided in the research for its effective formulation. The inclusion criteria for the research are articles published on and after 2013, written in English, fully accessible, related to smoking and lung cancer in adults, contain primary data and academic. The exclusion criteria for the research are articles published before 2013, contains secondary information, not written in English, do not contain data regarding lung cancer and smoking in adults and non-academic. The articles published on and after 2013 are included because they contain scientifically updated information regarding the study topic to ensure its effective execution through enriched data presentation. The articles published before 2013 are to be excluded because they may contain data which are backdated and currently been disregarded through advanced experimental results and findings. The articles which are academic are used because it contains information which are logically and scientifically proved through use of different protocols and tools.

The articles written in English are included because the information in them can be easily understood by the current researchers who belong from the UK having knolwdege regarding English as the only language. The articles written in other languages are excluded as it would led the researchers unable to understand and present valued information for execution of study, in turn, causing to raise error and lack of reliability of presented facts in the research. The articles containing information regarding lung cancer and smoking are to be included and others excluded as smoking is the key risk factors identified in the study to evaluate its impact on lung cancer among adults. The articles which are partially accessible with abstract only are excluded because such articles do not allow the researchers to develop detailed results to be presented in successful execution of the current study. The articles containing primary data are to be used as they contain information which are directly received from the participants and not manipulated during presentation by the researchers. Moreover, primary articles present greater authentication of data due to presence of cross-reference to the results presented in the study.

Data Collection

The exclusion and inclusion criteria led to identify that 6 potential articles are to be used in framing the study.

Data Analysis

The data analysis is to be performed by using thematic analysis method. The thematic analysis is the process in which data gathered are categorised in different themes to be presented in systematic manner within the study (Shepherd et al., 2015). The advantage of thematic analysis method is that it can be executed unsupervised without the requirement of any special training or skills by the researchers. Moreover, the process is flexible due to which it allows researchers to frame different themes and interpret gathered data in enhanced manner (Gobeil-Lavoie et al., 2019). The first step to be followed in performing thematic analysis is familiarisation with the data that is important to develop through review of the data gathered before analysing them as per individual terms. The second step is coding in which the data gathered are coded into different text and sentences in describing the content (Shepherd et al., 2015). The third step to be followed is generation of themes in which are wider codes combining the gathered data in systematic manner to be presented in the study (Shepherd et al., 2015). The themes developed are then to be reviewed and named for final presentation in the study (Shepherd et al., 2015). The CASP framework is to be used for critical analysis of the six studies included in the research. This is because it would help to develop increased clarity regarding the gathered information from the articles (CASP, 2018).

Summary

The above discussion mentions that systematic review method is to be used in executing the study and articles are to be chosen based ion exclusion and inclusion criteria. A total of 6 articles is to be included under 4 themes to explain the information gathered from the studies. The ethical context in the study is to be effectively managed to avoid violation of rules.

Chapter 3: Thematic Analysis

Theme 1: Identifying characteristics of smoking as risk factor for lung cancer

The theme is going to focus on identifying the characteristics smoking that leads to lung cancer among individuals. For this purpose, the study by Tindle et al. (2018) is explored that aimed to mention the link between risk of lung cancer and lifetime smoking history of individuals. The study to fulfil the aim analysed data from Offspring cohort (n=5002) and Framingham Heart Study Original (n=3905) participants for lifetime smoking and incidence of lung cancer initiating 1954-1958 and 1971-1975 respectively through the entire 2013. The study performed multivariate-adjusted Cox proportional hazard regression model for comparing the present, former and non-smokers in regard to risk of lung cancer. The results revealed that on follow-up for 28.7 years, 284 lung cancer to be identified. The incidence rates/1000 person each year in of the detected lung cancer include CI=1.6 for current, CI= 0.26 for never and CI= 1.97 for former smokers. It was seen that 89.5% of the smokers at the baseline ceased smoking during the follow-up period and never relapsed. On model being adjusted for education, gender, decade of examination and consumption of alcohol in comparison to current smokers, it is revealed that risk of lung cancer is lower for the former heavy smokers. The secondary analysis of the gathered data mentioned lower risk of lung cancer in former heavy smokers versus present smokers, but it is not true for the former smokers with 5-9-year history of smoking. The results mention that 58.7% of the lung cancer occurs in present and former smokers and among them 49 lung cancer are detected in former smokers who had smoking history of 15 years and more. 29.7% of lung cancer is reported to occur in people of 55-75 years of age. It is also revealed that 15.4% lung cancer occurred in people who smoked 30 packets of cigarettes a year. The strength of the study is that it is performed in consistent with previous studies which helped to provide reliability and validity of results. The other strength of the study is that it informs the way and to extent to which smoking influences risk of lung cancer. However, the limitation is that the sample size used is considered to be smaller compared to the previous studies. The other limitation is that factors such as radon exposure, genetic variation and other impact on smoking and risk of lung cancer are avoided to be considered in performing the study.

Similarly, the study by Ban et al. (2020) aimed to determine the characteristics and prognosis of smoking in patient in actual lung cancer cohort individuals. For this purpose, 439 patients from the lung cancer cohort of the Catholic University of Korea from 2014 to 2017 were included. The patients are categorised into low-risk and high-risk groups on the basis of their history of smoking by use of the national guideline for lung screening. The results revealed that 53.1% (226) patients were present in high-risk group and 46.9% (206) patients are present in the low-risk group. The high-risk group included 97% men and the low-risk group included 16% men. The characteristics of the high-risk group are low BMI, male, advanced stage of lung cancer, poor driver for mutation, poor histological differentiation and poor pulmonary condition. The characteristics of low-risk groups are increased BMI, les presence of comorbidities, lower cancer expression and others. The average packets and smoking years and abstinence ranged 55 and 5.3 years among the patients in high-risk group and 11.2 and 15.1 years among the patients present in the low-risk groups. The cumulative exposure of smoking was found to be significantly present in lower percentage in the low-risk group. The medial survival time of high-risk patient in 542 days and for low-risk group is 1082 days. The results further revealed through time-dependent ROC curve smoking 40 packets of cigarette in a year and 18.75 packets in a year lead to patient die within 1 and 3 years of detection of lung cancer. A statistically significant data was recovered on analysis of patient survival and smoking rate indicating that increased year of smoking led to lower survival rate in patients. The limitation of the study is that it included analysis of patient of particular age and not lung cancer patients of all ages which limited the determination of characteristic of smoking to influence lung cancer and individuals of different age group. The other limitation is that the study expressed low specificity for the cut-off points regarding impact of smoking and smoking rate. The other limitation is that it is retrospective study due to which personal influence of reporting data by the participants may lead to influence development of error in result presentation. However, the medical records are found to faithfully collected and re-examined to ensure its authentication by the authorities which acted as strength in the study to resolve the limitation.

Theme 2: Impact of smoking on causing lung cancer in patients

The lung cancer is considered as one of the key causes of deaths related to cancer and cigarette smoking is one of the key risk factors for the condition. The study by Huang et al. (2014) aimed to determine the deregulating impact of cigarette smoking on serum microRNA which is related to lung cancer expression in individuals. In order to fulfil the aim, the study is executed in 3 phases which included three serum samples that are from 10 smokers, 10 non-smokers and 10 lung cancer patients for identifying the association of smoking and lung cancer with serum iRNAs. The result for the study is developed by comparing three of the mentioned groups. The results which included comparison of differentially expressed miRNAs of smokers and non-smokers revealed that 105 miRNAs are highly expressed in altered state within the serum sample of the people involved in smoking than the non-smokers. The 32 and 37 candidates of miRNAs are expressed in upregulated and downregulated manner respectively. In smokers, 73 candidates of miRNAs are found to be significantly altered who are suffering from lung cancer and 56 candidate of miRNAs and 17 candidates of miRNAs were upregulated and down regulated in lung cancer patients. It is further revealed that out of 85 differentially expressed miRNAs, 80.95% of them are present in smokers and 52.15% of them are present in non-smokers indicates influence of smoking on miRNAs that results in lung cancer development in smokers. The let-7i-3p and miR-154-5p are found to be downregulated in smokers and lung cancer patients which indicates that the serum level of let-7i-3p and miR-154-5p are related with causing lung cancer among smokers. The let-7i-3p is considered as an important part of let-7 family that assist in regulating different essential ling cancer related oncogenes and inhibits the cancerous growth in lungs. The strength of the study is that it informed the impact on smoking on the genetic construct and functioning of the body that results individuals to develop lung cancer. However, the limitation is that it failed to mention physical impact of smoking that leads individuals to be at risk of developing lung cancer.

Theme 3: Analysing the challenges faced by lung cancer patients during smoking cessation

In controlling risk of lung cancer in patients, smoking cessation is one of the ways to achieve the condition. However, it is seen that challenges are being faced by lung cancer patient to achieve smoking cessation which leads to suffer further. In this aspect, the study by Davidson et al. (2018) evaluated the impact of Smoking Cessation Program organised at the London Regional Cancer Program for a 2-year period of study. The was initiated in March 2014 and ended in 2016 where a total of 6613 patients who are smokers or current smokers with risk or suffering from lung cancer are included. In 2015, 5090 (77%) of the patients are screened for use of tobacco and it was identified that 18% of them are current smokers. Nearly 84% of the patients who are smokers with risk and/or suffering from lung cancer are advised regarding the benefit of smoking cessation program, but 13% of them only accepted and showed involvement in the program. In 2016, 6627 patients are registered for the program and 5251 (79%) of them are finally screened for tobacco use and risk of lung cancer. Among them, 18% were identified to be current smokers. 78% of them were educated regarding benefit of smoking cessation program and 9% accepted referral and 2% involved in the enrolment for follow-up. The challenges identified from the program that led the smokers who are at risk or suffering from lung cancer face challenges of involvement in smoking cessation are limited information of referral and counselling for smoking cessation, hindered access to Nicotine Replacement Therapy (NRT), minimum follow-up and others. The limitation of the study is that it determines limitation of a specific smoking cessation program for smokers and lung cancer patient and not the topic as a whole to understand the social and environment barriers fir smoking cessation among the smokers and lung cancer patients.

Theme 4: Strategies to prevent lung cancer among smokers

One of the strategies to prevent lung cancer in smokers is influencing them to involve in smoking cessation. In this context, the study by Taylor et al. (2017), evaluated the impact of telephone-based smoking cessation intervention success in managing lung cancer risk and suffering among patients. The study organised by using randomised control trail design in which the efficacy and feasibility of the telephone-counselling smoking cessation intervention is compared against usual care in the lung cancer screening settings. The study led to enrolled patients who are 50-77 years of age and involve in smoking more than 40 packets of cigarettes in a year. The participants are asked to complete the questionnaire pre and post attendance of telephone-based smoking cessation. The counselling calls involved motivational interviewing and used screening results fort promoting smoking cessation among individuals. The outcomes in the study is biochemically identified 7-day point prevalence cessation at 3-month randomisation. The results revealed that 56.5% of the participants are female and their average age if 60.2 years with 47.1 packets of cigarettes being smoked by the patients on an average each year. After the cessation program, it was identified that 30% of the participants initiated to cease smoking within 30 days. The intent-to-treat analysis mentions that 17.4% of the patients who attended telephone-based smoking cessation program show willingness to quit smoking compared to 4.3% of patients who received usual care for lung cancer screening and management. The limitation of the study is that it involved small sample size with brief follow-up results that made the researchers fail to ensure lower variability of results which eventually led to development of bias in the study. However, the strength of the study is that biochemical verification is used to determine the impact of the program and cessation rates are identified between the two compared group to understand which of them is potential to be followed for lung cancer prevention in smokers.

In comparison, the study by Garon et al., (2015) aimed to mention the effect of pembrolizumab in treatment of lung cancer among smokers and non-smokers. For this purpose, the study included 495 patients who are administered pembrolizumab. Among them, 182 patients are recruited to the training group and 313 patients are recruited to the validation group. The validation group is the one in which validation of tumour PD-L1 expression is related to likeliness of benefit of pembrolizumab. The results revealed that common side-effects of pembrolizumab are fatigue, decreased appetite and pruritus which are appear irrespective of dose or schedule of the drug. Among the patient, the positive response for the drug was 19.4% and the median duration was 12.4 months for the drug use. The drug was effects in 22.5% smokers who were suffering from lung cancer compared to 10.3% non-smokers who are suffering from lung cancer. PD-L1 expression with at least 50% tumour cells was identified as cut-off for the patients involved in training group. The median progression-free survival score developed by use of the drug is 6.3 months. The limitation of the study is sample size which lead to create hindered development of confidence interval for response received in the study. However, the strength of the study is that it effectively determines the extent of toxicity and side-effect of the medication to identify its ability of use in effective treatment of lung cancer in patients.

Chapter 4: Findings and Discussion

According to the studies identified in relation to the research topic, it initially mentions that smoking is a major risk factor for lung cancer development in patients. It is evident from the study of Tindle et al., (2018) which informed that smokers who are actively involved in smoking are at increased risk of developing cancer. It was identified that individuals who ceased smoking in the last 5 years expressed 39.1% lower risk of facing lung cancer in comparison with the current smokers. The relative low risk of lung cancer incident is mentioned to be rapid in the current study than the other prospective study of Courtney (2015) and information regarding health benefits of cessation of smoking. In the study, it is reflected that as year of smoking quotient increased, the risk of lung cancer in the former smokers were found to be reduced compared to the active smokers and yet lung cancer risk was found to remain elevated at three time more for never smokers even after 25 years of smoking cessation. Thus, the study failed to mention the link of never smoking condition with increased risk of lung cancer and ensure if smoking is the only key factor for the risk of cancer.

The persistent presence of increased risk of lung cancer among former smokers indicates key implications to be made for lung cancer screening as 40.8% of the cancer was found to be present among former smoker after 15 years of quitting (Tindle et al., 2018). The information in the study is consistent with other studies of Jeon et al., (2018), O’Keeffe et al., (2018) and Joseph et al., (2018) where it is also mentioned that cigarette smoking increases risk regarding lung cancer in current, as well as former smokers and cessation of the habit, would reduce the risk. However, the study fails to inform with support of evident whether smoking influence all nature of lung cancer or any particular type. Moreover, it fails to inform the histological characteristics of lung cancer that are influenced by smoking habit in smokers and quitters.

The study by Ban et al. (2020) mainly explored the clinical characteristics influenced by smoking that result in expression of lung cancer in patients. The study reveals that more exposure to prolonged smoking influenced increased risk of cancer like the previous study by Tindle et al., (2018). This is because exposure to tobacco smoke creates initiation of oxidative stress at the cellular level which leads to cause genetic damage. The normal cells on being transformed into cancerous cells create increased mutation burden and poor histological expression of cells in the body. It also influences induction of chronic airways and inflame them which leads to hindered function of the lungs and initiation of sarcopenia which are related with prognosis of lung cancer (Zaynagetdinov et al., 2016). In the current article, the adjustment of the cancer stage which had significant survival effect is made and yet survival rate of high-risk group was found to be decreased significantly in advanced stages (III, IV) as well as in early stages (I, II).

The study by Filipska and Rosell (2021) has mentioned that intolerance towrads treatment and co-morbidities of the patient with lung cancer are essential factors for poor prognosis of the disease. However, in the current study, no statistical different results in respect to comorbidities among long and high-risk patients are identified that ensure poor prognosis of the cancer. The study also highlighted that smoking is able to cause negative effect on the pharmacokinetics of the drug and efficiency of impact of chemotherapy in patients with advanced lung cancer. Thus, it indicates that continued smoking in lung cancer patients apart from initiating the cancer also acts as barrier towards its enhanced treatment. The exploration of the study further revealed that smoking creates dose-dependent relation in respect of patient survival. This is evident as increased intake of cigarettes packets each year indicates high-risk of lung cancer among individuals. The study has informed that those smoke 40 cigarette packages a year are more to lung cancer and less survival compared to those who smokes 15 cigarette packets in a year.

The previous studies by Cazzoli et al., (2013) and Tang et al., (2013) informs that miRNAs are key biomarkers for different nature of cancer and cigarette smoking is able to change the profiles of serum miRNAs of healthy subjects to make them be at risk of lung cancer. Thus, to develop a clear view regarding the relation between smoking and lung cancer, the changes in miRNAs are explored in smokers and lung cancer patients in the study by Huang et al. (2014). This is to gather information about the specific miRNAs being changed or altered due to the impact of smoking in smokers and patients of lung cancer. The microRNA array and culturing analysis in the study showed that 105 miRNAs levels are expressed in different form in the sera of the smokers compared to people who are not involved in smoking. Moreover, miRNAs are downregulated in the active smokers. The miRNA is mainly involved in expression of multiple type of messenger RNA. The downregulation of the miRNA leads to hindered mRNA expression which create dysregulation in the functioning of the cells leading individual to develop cancerous growth (Castro et al., 2017). Thus, down regulation of miRNAs caused by smoking leads to indicate that tobacco smoke suppression effect of miRNA for gene translation and transcription.

The study by Mathis et al., (2013) mentioned that downregulation of miRNA in smokers that rule in cancer occurs in the bronchial epithelium. Thus, the let-7i-3p and miR-154-5p are required to be over-regulated in supressing lung cancer. The fact is evident from the study of Zhao et al., (2018) where it is mentioned that overregulation of let-7i-3p in lung cancer patients helps in supressing the cancer cell and promotes cell apoptosis along with cell cycle arrest. The study also informed that downregulation of let-7i-3p and miR-154-5p is caused by smoking which leads to increased expression and risk of lung cancer. The information is still supported by the advanced study executed by Lee et al., (2021) where it is mentioned that let-7i-3p and miR-154-5p are potential biomarkers of lung cancer which are influenced by smoking habit in individuals. The current study by Huang et al. (2014) informed through ROC curve analysis that ACUs for the miR-154-5p and let-7i-3p serum were 0.957 and 0.892 respectively. This indicates that miR-154-5p and let-7i-3p are both potential biomarkers and has significant role to be played during tobacco smoke exposure and lung carcinogenesis induced by cigarette smoking. However, the study has failed to inform the exact origin of the circulating miRNAs which are being affected by smoking and the way they function in the serum which is being disrupted by the smoking activity that leads to expression of lung cancer in patients.

The smoking cessation is considered as first action required in managing lung cancer risk and suffering in patients. However, it is seen from previous data that instead of presence of adequate smoking cessation program, the lung cancer patients fail to effectively quit smoking. The study by Davidson et al. (2018) focussed to understand regarding the aspect to determine the factors that are creating challenge for smoking cessation among lung cancer patients and others who are actively involved in smoking. The study revealed that patients who show lesser symptoms of lung cancer, at the pre-contemplation stage of readiness to accept quitting smoking and diagnosis of head and neck cancer show less interest to be involved in smoking. This is because the lesser symptoms and lack of ready attitude to make change their existing behaviour of smoking makes the patients feel the smoking cessation process to be useless (Tremblay et al., 2019). The other reason given by patients to face challenge in smoking cessation is willingness to personally manage the condition to change the behaviour which they are unable to achieve due to lack of professional support and planned care goals. The fact is supported by the study of Short et al., (2017) where it is mentioned that self-attempt to cessation of smoking fails among individual due to lack of constructive ideas and presence of resources for systematically quitting the behaviour through control of side-effects while cessation such as insomnia and others.

The study revealed that oncologist most of the time enquire regarding tobacco use by individuals but only few times they are seen to be actively involved in advising patients regarding the process or if it is possible for them to quit smoking in real. Thus, the lack of enhanced referral for counselling and smoking cessation leads lung cancer patients and others to face challenge in achieving smoking cessation (Davidson et al., 2018). There is also lack of training among clinicians and nurses been reported that is leading cancer patients unable to effectively achieve smoking cessation. This is because without training, the clinicians are unable to recognise the way in which cancer patients are to be supported to effectively quit smoking. The lack of patient readiness to quit also acts as challenges for achieving smoking cessation in lung cancer patients. This is because their unwanted behaviour to accept the changes makes it difficult to actualise the behaviour change of smoking cessation.

The exploration of the study by Taylor et al., (2017) informed that a telephone-based smoking cessation program is one of the effective interventions in improving health of lung cancer patients. This is because it is feasible along with effacious to be delivered to any individuals irrespective of physical barriers and time. The telephone counselling for smoking cessation is at the intersection of intensity and scalability, both of which are needed for effective smoking cessation among lung cancer patients. The process also helps in enhancing the cost-effectiveness of smoking cessation process among patients. This is evident as no travelling to places is required and people can be conveyed over the phone regarding the actions to be taken to quit smoking. It also helps in effective follow-up of the smoking cessation among patients because effective reporting can be received over telephone to determine the progress of the patient. The fact is supported by the study of Tremblay et al., (2019) where it is mentioned that telephone counselling of smoking cessation leads to effective control of smoking habit among lung cancer patients. However, the limitation of using telephone counselling for smoking cessation is that support workers providing the intervention are unable to physical assess the progress of the patient and rely on their word-of-mouth to understand the progress which may be wrongly mentioned by the patients to avoid further interference from the workers.

The smoking cessation acts to lower risk of lung cancer but effective pharmacological along with clinical treatment is required to manage lung cancer. This is because lung cancer develops worsened condition without treatment and results in metastasis which compromises the survival of the patient (Minnix et al., 2018). In this context, the study by Garon et al., (2015) is analysed to determine one of the effective medications to be used for treatment of lung cancer in patients who are smokers or non-smokers. The study mentioned that Pembrolizumab is one of the medications with least toxicity and side-effect to be used in treatment of lung cancer. It is evident as it creates common side-effects like loss of appetite, fatigue and others which can be controlled with basic health management by the patient. The fact is also supported by the study of Paz-Ares et al., (2018) where it was mentioned that Pembrolizumab provided in association with chemotherapy involving arboplatin plus paclitaxel or nab-paclitaxel to squamous cell lung cancer patients and metastasis lung cancer patients assist in longer survival of the patients along with ensures progression-free survival rate of the patient. However, the study mentions that Pembrolizumab could be effective in patients with lung cancer who has at least 50% expression of PD-L1. The PD-L1 is referred to as the protein which avoids the immune cells from attacking non-harmful cell in the body (Mok et al., 2019). The criticism regarding the study is that it does not involved a non-pembrolizumab comparator to asses the prognostic implication of PD-L1 expression. The results of the current study though are inconsistent regarding PD-L1 expression and non-mall cell lung cancer, but, the studies by Sun et al., (2014) and Sorensen et al., (2014) does not approve PD-L1 expression to have prognostic effect in lung cancer. In this condition, the administration of Pembrolizumab becomes questionable for the patients as the delivery of the drug is dependent on the prognosis of the condition with the expression of PD-L1.

Chapter 5: Conclusion and Recommendation

Conclusion

The study focuses to determine the relation and impact of smoking on lung cancer. In this purpose, a background of the study is presented where the detailed concept regarding smoking tobacco is mentioned. The concept concludes that tobacco smoke is addictive substance as it causes production of endorphins and dopamine on being inhaled that promote happy feeling and assist people to overcome stress. Globally 7 million people are mentioned to faced death due to tobacco smoking each year and among them mostly faced respiratory problem and cancer as the reason for their mortality. Smoking acts as key factor for promoting lung cancer in patients. This is because chemical substances present in tobacco smoke are carcinogens that acts to cause disruption of the metabolic management in the body due to hindered gene expression. The carcinogens responsible for causing lung cancer include Polycylclic Aromatic Hydrocarbons (PAH), 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), N'-nitrosonornicotine (NNN) and others. They are seen to act as tumour promoting agents leading to activation of activation of β-adrenergic receptors (β-AdrRs) and nicotinic acetylcholine receptors (nAChRs) promotes signal transduction to support tumour formation. The aim of the study determine is analysis of impact of smoking cigarettes as risk factor for patients with lung cancer. In order to perform the study, four objectives are developed that would be followed.

The topic is chosen to be performed because lung cancer is second common type of cancer that is diagnosed globally among people. In the UK, nearly 1 in 15 female and 1 in 13 males are suffering from lung cancers who are found to be potential smokers at large. Moreover, Hungary has the highest rate of lung cancer that is 56.7 per 100,000 population whereas in UK, it is 32.5 per 100,000 population as observed within Europe. The increased incidence of lung cancer and smoking has become an issue because it leading to increased mortality among people. It is evident 3 in 20 of people diagnosed with lung cancer in the UK are seen to survive 5 years or more and many of them are found to be active or former smokers. Therefore, focus on the problem is required so that better understand regarding the ay smoking influences lung cancer in patients can be determined. Moreover, the focus on the topic is required to understand the way smoking impact in creating increased risk of lung cancer in people.

The study is to be performed by following the systematic review process instead of literature review. This is because it helps in methodically analyse the question and accordingly gather data to be presented in critical manner within the study. However, literature review leads to presentation of data in a comprehensive manner with no analytical view of the information in regard to the topic. The PICO framework is followed for formulating the study question. Thee PRISMA framework is followed to present the flowchart of the way gradually the limited ix articles for the study is chosen in meeting the aim of the research and resolve the raised question. The electronic search strategy is been used with implementation of keywords. The inclusion criteria and exclusion criteria are developed based on the topic. The thematic analysis process is used for analysis data and presenting information gathered under themes. A total of six articles are gathered for performing the study.

The results revealed that smoking is major factor for lung cancer and with increased amount of smoking of cigarettes, the risk of lung cancer increases for the individuals. Moreover, the increased years of smoking cigarettes is proportional to the risk of lung cancer and increase mortality risk among people. The smoking creates downregulation of the let-7i-3p and miR-154-5p along with other miRNAs that lead to promote the cancerous growth in the body. The challenges faced in smoking cessation among people with lung cancer are lack oif effective referral by physicians, hindered access to Nicotine Replacement Therapy (NRT), minimum follow-up and others. The use of telephone-based smoking cessation counselling is effective way to achieve smoking cessation in people and it limits the risk of lung cancer. The use of pembrolizumab is identified to be effective medication with chemotherapy in treatment and management of lung cancer.

Recommendations

The recommendations developed from the study are as follows:

Improve smoking cessation process and program: The evaluation of the studies proved smoking cigarettes is one of the major factors that causes lung cancer as it leads to later the genetic expression in the body. Thus, one of the key recommendations is supporting enhanced smoking cessation program development which is holistically available for all nature of smokers and lung cancer patients as well as any other cancer patients. The local and national authorities in the UK as well as globally are recommended to develop increased responsibility in researching new ways through which smoking cessation program can be developed so that challenges faced towards its use by the smokers and lung cancer patients are not faced. The programs are to be made available online and offline for target participants and effective resources are to be present as well as provided to the patients who are intending to quit smoking. The program is recommended to include information that provides detailed knolwdege regarding the benefit of smoking cessation education to the target patients so that they develop willingness out of enhanced perception to quit smoking. The program is required to include process that allow easier referral of patients to it by the healthcare professionals and recommended to include increased number of staffs to ensure no patients are avoided due to care-related issue to effectively involve in the program.

Pharmacological intervention for treatment of lung cancer:

The analysis of the studies mentioned one drug that could be used in treatment of lung cancer and it is found to be provided dependent on the level of genetic expression caused in the body out of presence of lung cancer. However, knolwdege regarding additional medications are to be included. Thus, it is recommended that information about chemotherapy is to be available to the lung cancer patients. This is because chemotherapy involves use of medication to destroy the cancerous cells in the body which assist in keeping the cells from growing and diving to make more cells and worsen the condition. The common drugs recommended to be used by lung cancer patients are carboplatin, Nab-paclitaxel, vinorelbine and others.

Early health promotion to avoid smoking habit:

The recommendation is that increased focus on preventing the development of smoking habit at the early stage is to be established. This is because it would help in avoiding the risk of lung cancer as well as eliminate suffering from disease among people who develops the lung cancer due to their increased smoking habit. In order to promote avoidance of smoking habit, effective education regarding the harmful effect of smoking with evidence is to be provided to the children at the early stage. Moreover, the parents of children who are smokers or non-smokers are to be involved in the program along with their children to understand regarding the way the habit and social circumstance could promote use of tobacco smoking in the child and way it would led the person to be at increased risk of suffering from lung cancer. It is also recommended that effective counselling opportunities are to be present for the children as well as teenagers to make them realise the way they can avoid smoking as a habit in their everyday life by tackling social and environmental influences.

Training of Healthcare staff and Clinicians:

One of the studies mentioned that healthcare staffs and clinicals does not have effective opportunity to refer identified smokers for smoking cessation process and lack ability to execute follow-up on the process. Thus, the recommendation is that healthcare professionals and staffs are to be trained regarding the way they can actively influence and refer smokers to involve in smoking cessation process and program. This is because the training would make the clinicians and staffs develop enhanced skills and knolwdege required by them to efficiently refer smokers who are at risk or suffering from lung cancer to smoking cessation programs. Moreover, the training is essential to make the staffs and clinicians understand the way their role in promotion of smoking cessation among smokers and lung cancer patients is important and the way they can follow-up thee patient to ensure they achieve effective smoking cessation.

Non-pharmacological intervention for treatment of lung cancer:

The other recommendation is that non-pharmacological interventions are to be taken to support enhance treatment of lung cancer in smokers. The lung cancer patients are recommended to take green team polyphenols in the diet as they help in upregulation of p53 gene through phosphorylation and enhancing its transcriptional activity. It also acts to upregulate miR-210 expression, increase E-cadherin expression, inhibit TFGF-βmigration, decrease vimentin expression and others that are essential for limiting cancer cell progression in the body (Khan and Mukhtar, 2015). The food which contain isothiocyanates such as green vegetables, water cress, brussels sprouts and others are to be included in the diet of the smokers with risk of lung cancer. This is because the component in the food helps in induction of apoptosis that assist in destruction of cancerous cells in the body (Khan and Mukhtar, 2015).

Chapter 6: Reflexivity

The development of the research paper regarding smoking cigarettes or tobacco as risk factor for lung cancer was quite challenging as I did not have enough information regarding the topic at the initial stage. The initial difficulties experienced by me are increased number of online articles been present regarding the topic, failing to develop the themes and determine the exact objectives to be focussed in the study. The additional challenges made me to develop panic, but I tried to internalise the condition to develop confidence and develop the study. I internalise the facts and accepted the challenge by thinking that previously I have faced many hindrances in life which I was able top personally resolve through effective thinking which I have to current include in the study too.

In order to resolve the challenges, I tried to develop communication with my lecturer and peers. My peers were found to be similar puzzled like me and therefore, I approached my lecturer who provide detailed notes regarding the step to be followed in writing a dissertation. IT Helped me to most extent overcome my panic and execute the study. In order to develop the objective of the study, I initially tried to gather basic information regarding the study which are explored by me to determine how the objectives in the current study are to be set so that it meets the topic name as well as ensures new information to be presented in regarding the topic. The issue regarding presence of many information to be included in the study was resolved by me through categorising the information at per with the objectives been developed.

The study led me to learn regarding the way Harvard referencing is to be made which I have never done previously. I took help from the internet and lecturer to determine the steps to be followed in framing the reference. I faced issues with time management in the study as wide number of actions are to be performed within minimum time. In this respect, my peers suggested me to develop a timetable to be followed to schedule my task according so that I can meet them in time which was effective to resolve the challenge. The study led me to realise the way existing information are to be gathered to be presented in framing a new topic. Moreover, the study helps me to understand the way effective knolwdege regarding any unknown is to be gathered to effectively complete it.

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