Iris Kanera

158 Chapter 7 Ostroff, 2005; Westmaas et al., 2014). The proportion of smokers among our cancer survivor population is comparable to the Dutch population aged 50 - 64 (25.9%) and 65 - 75 years (16%; National Institute for Public Health and Environment, 2016b). Importantly, smoking may negatively influence cancer recurrence rates (Bishop, Killelea, Chagpar, Horowitz, & Lannin, 2014). Therefore, support in smoking cessation should be part of lifestyle promotion interventions targeting cancer survivors, a need also expressed by Dutch cancer survivors (Willems et al., 2016). Social cognitive correlates of smoking In Chapter 2, being a nonsmoker was correlated with higher self-efficacy, a positive attitude toward nonsmoking, lower anxiety, and better social functioning. Prior research on this topic is scarce and confirmed our findings on self-efficacy (Del Valle et al., 2014). Thus, self-efficacy to quit smoking and a positive attitude concerning nonsmoking are relevant factors that should be included in smoking cessation interventions for cancer survivors. Prevalence of alcohol consumption National and international adherence rates of alcohol recommendation (33% - 90%) varied to our findings (75.4%), being in the middle ranking range and in line with other Dutch studies (Bidstrup et al., 2013; Bours et al., 2015; Del Valle et al., 2014; Niu et al., 2015; Weaver et al., 2013a; Winkels et al., 2016). However, it is important to note that in our study 24.6% exceeded the alcohol recommendation, which is higher compared to another Dutch cancer survivor population (14%; Holtmaat, van der Spek, Cuijpers, Leemans, & Verdonck-de Leeuw, 2017), in the middle range compared to American cancer survivors (18% - 56%; Potash, Karnell, Christensen, Vander Weg, & Funk, 2010; Schootman et al., 2013; Weaver et al., 2013a), and higher compared to the Dutch general population aged 55-64 years (10%) and aged older than 65 years (7.4%; National Institute for Public Health and Environment, 2016a). Exceeding the alcohol recommendation was found to be associated with cancer recurrence among survivors of breast cancer (Kwan et al., 2010; McLaughlin et al., 2014; Weaver et al., 2013a). Given the relatively high proportion of excessive drinkers in our study, attention should be paid to the amount of alcohol consumed by survivors in cancer aftercare. Social cognitive correlates of alcohol consumption The study in Chapter 2 showed that lower self-efficacy was associated with higher alcohol consumption as confirmed by other studies (Del Valle et al., 2014). The need for assistance to reduce alcohol intake was found to be very low among Dutch cancer survivors, as reported by Willems et al. (2016). This might be a result of not wanting to be labeled as an “excessive drinker”, and a low risk-perception regarding alcohol consumption and cancer recurrence, or an overestimation of a presumed anti-stress effect. The provision of adequate information