Iris Kanera

46 Chapter 2 Higher scores on self-efficacy lower ages, more pain, and more fatigue were the only significant correlates of a higher level of PA. Causal directions cannot be determined, but a possible explanation for the positive relationships between pain respectively fatigue and a higher level of PA could be, that pain and fatigue might have been reasons to get supervised by an (oncological) physiotherapist, or to follow a rehabilitation program. In the Netherlands, guidelines to cope with pain and fatigue are characterized by an active approach (gradually building up PA). As described before, PA is an important modifiable lifestyle behavior, which can have an impact on health outcomes in cancer survivors. Even though most of the cancer survivors meet the recommendations in our study, in clinical practice, attention should be given to the maintenance and if possible, to a gradual increase of PA. Smoking Of our sample, 18% were current smoker, which is a higher rate of smokers compared to findings fromother research (Del Valle et al., 2014;Weaver et al., 2013b;Westmaas et al., 2014). Most of the former smokers quitted before cancer diagnosis, and half of the current smokers intended to quit within six months. The strongest correlates of not smoking were a higher self-efficacy, a more positive attitude toward nonsmoking, lower anxiety and better social functioning, while in other research, where social cognitive and psychological variables were not considered, younger age, lower education/ income, greater alcohol consumption, and cancer type were correlated with current smoking (Westmaas et al., 2014). However, qualitative results of Berg et al. (2013), confirmed that a positive attitude towards quitting may help to (remain) quit, and that feelings of anxiety and low self-efficacy were reasons to continue smoking, which corresponds to our results. Additionally, addiction and habit were also mentioned as important reasons to continue smoking. However, our study did not confirm their result, that depressive symptoms were correlated with continued smoking, possibly due to the low prevalence of depressive symptoms in our sample. Besides above mentioned findings, concepts of addiction and habit and a possible interaction with other risk behaviors (e.g., alcohol consumption) should be taken into consideration in further research. Because of the increased health risk of continued smoking, the high rate of motivated current smokers, and limited research in this field, further exploration of predictors and the development of programs to (remain) quit smoking for cancer survivors are needed. Alcohol consumption Among alcohol drinkers, more than one third drank more than recommended, and 18.7% preformed binge drinking (six or more glasses a day, 1-3 times per month or even more