Achieving Equity in the Reach of Smoking Cessation Services Within the NCI Cancer Moonshot-Funded Cancer Center Cessation Initiative

Understanding cancer patients' desire to quit tobacco without assistance: A mixed-methods study

While many cancer patients who use tobacco try to quit post-diagnosis, some prefer to quit without using tobacco treatment, despite evidence against unassisted quit attempts. This study aimed to understand the rationale for some cancer patients' desire to quit tobacco without assistance. Thirty-five adult cancer patients who currently used tobacco and declined tobacco treatment because of the desire to quit unassisted provided data via a standardized questionnaire and a semi-structured interview. The sample was predominately White, non-Hispanic (85.71%) and female (68.57%). The most common cancer site was gynecological. Key themes that emerged from the interviews were: self-reliance, willpower, social norms, and negative attitudes toward tobacco treatment. The most frequently endorsed barrier to tobacco treatment was "I know others who have quit without tobacco treatment" (82.86%). This study with cancer patients identified affective, cognitive, and personality factors related to quitting unassisted, and social and systemic reasons to not use tobacco treatment.

Nursing leadership in tobacco dependence treatment to advance health equity: An American Academy of Nursing policy manuscript

BACKGROUND

Tobacco use remains the leading cause of preventable disease, disability, and death in the United States and is a significant cause of health disparities.

PURPOSE

The purpose of this paper is to update the Tobacco Control policy paper published over a decade ago by the American Academy of Nursing's Health Behavior Expert Panel Tobacco Control subcommittee.

METHODS

Members reviewed and synthesized published literature from 2012 to 2024 to identify the current state of the science related to nurse-led tobacco dependence treatment and implications for nursing practice, education, and research.

FINDINGS

The results confirmed that nurse-led tobacco dependence treatment interventions are successful in enhancing cessation outcomes across settings.

DISCUSSION

Recommendations for nursing leaders include: promote tobacco dependence treatment as standard care, accelerate research on implementation of evidence-based treatment guidelines, reduce health disparities by extending access to evidence-based treatment, increase nursing competency in providing tobacco treatment, and drive equity-focused tobacco control policies.

Feasibility of precision smoking treatment in a low-income community setting: results of a pilot randomized controlled trial in The Southern Community Cohort Study

BACKGROUND

The feasibility of precision smoking treatment in socioeconomically disadvantaged communities has not been studied.

METHODS

Participants in the Southern Community Cohort Study who smoked daily were invited to join a pilot randomized controlled trial of three smoking cessation interventions: guideline-based care (GBC), GBC plus nicotine metabolism-informed care (MIC), and GBC plus counseling guided by a polygenic risk score (PRS) for lung cancer. Feasibility was assessed by rates of study enrollment, engagement, and retention, targeting > 70% for each. Using logistic regression, we also assessed whether feasibility varied by age, sex, race, income, education, and attitudes toward precision smoking treatment.

RESULTS

Of 92 eligible individuals (79.3% Black; 68.2% with household income < $15,000), 67 (72.8%; 95% CI 63.0-80.9%) enrolled and were randomized. Of these, 58 (86.6%; 95% CI 76.4-92.8%) engaged with the intervention, and of these engaged participants, 43 (74.1%; 95% CI 61.6-83.7%) were retained at 6-month follow-up. Conditional on enrollment, older age was associated with lower engagement (OR 0.83, 95% CI 0.73-0.95, p = 0.008). Conditional on engagement, retention was significantly lower in the PRS arm than in the GBC arm (OR 0.18, 95% CI 0.03-1.00, p = 0.050). No other selection effects were observed.

CONCLUSIONS

Genetically informed precision smoking cessation interventions are feasible in socioeconomically disadvantaged communities, exhibiting high enrollment, engagement, and retention irrespective of race, sex, income, education, or attitudes toward precision smoking treatment. Future smoking cessation interventions in this population should take steps to engage older people and to sustain participation in interventions that include genetic risk counseling.

TRIAL REGISTRATION

ClinicalTrials.gov No. NCT03521141, Registered 27 April 2018, https://www.

CLINICALTRIALS

gov/study/NCT03521141.

Predictors of Patient Engagement in Telehealth-Delivered Tobacco Cessation Treatment during the COVID-19 Pandemic

Smoking causes one in three cancer deaths and may worsen COVID-19 outcomes. Telehealth tobacco cessation treatment is offered as a covered benefit for patients at the Stanford Cancer Center. We examined predictors of engagement during the COVID-19 pandemic. Data were abstracted from the Electronic Health Record between 3/17/20 (start of pandemic shelter-in-place) and 9/20/22, including patient tobacco use, demographics, and engagement in cessation treatment. Importance of quitting tobacco was obtained for a subset (53%). During the first 2.5 years of the pandemic, 2595 patients were identified as recently using tobacco, and 1571 patients were contacted (61%). Of the 1313 patients still using tobacco (40% women, mean age 59, 66% White, 13% Hispanic), 448 (34%) enrolled in treatment. Patient engagement was greater in pandemic year 1 (42%) than in year 2 (28%) and year 3 (19%). Women (41%) engaged more than men (30%). Patients aged 36-45 (39%), 46-55 (43%), 56-65 (37%), and 66-75 (33%) engaged more than patients aged 18-35 (18%) and >75 (21%). Hispanic/Latinx patients (42%) engaged more than non-Hispanic/Latinx patients (33%). Engagement was not statistically significantly related to patient race. Perceived importance of quitting tobacco was significantly lower in pandemic year 1 than year 2 or 3. Nearly one in three cancer patients engaged in telehealth cessation treatment during the COVID-19 pandemic. Engagement was greater earlier in the pandemic, among women, Hispanic/Latinx individuals, and patients aged 36 to 75. Sheltering-in-place, rather than greater perceived risk, may have facilitated patient engagement in tobacco cessation treatment.

Development and Demonstration of Tobacco Treatment Measures for Cancer Registries: Novel Metrics for Quality Improvement

BACKGROUND

Individuals undergoing cancer treatment have better outcomes when they discontinue tobacco use. Few cancer centers systematically provide evidence-based cessation services. As part of a national quality improvement initiative [Cancer Center Cessation Initiative (C3i)], we collaborated with our cancer registry to develop and implement two tobacco treatment metrics for tracking the provision of behavioral support and pharmacotherapy.

METHODS

Post-development, the tobacco treatment metrics were integrated into the registry for all future patients. We used means and frequencies to summarize tobacco treatment for cases treated between 2017 and 2019, coinciding with the timeframe of C3i participation.

RESULTS

Of 17,735 cancer cases reviewed, both measures were captured on 17,654 (99.5%) of patients, with 3,091 (17.4%) identified as users of tobacco. Across the 3 years, 557 (18%) of individuals who used tobacco received either tobacco cessation pharmacotherapy or behavioral support; with 478 (15.5%) receiving behavioral counseling, 352 (11.4%) receiving pharmacotherapy, and 273 (8.8%) receiving both-considered gold standard care. Tobacco treatment varied substantially across cancer types. The odds of receiving gold standard care were 2.37 times greater in 2019 compared with 2017. (OR, 2.37; 95% confidence interval, 1.63-3.46; P < 0.0001).

CONCLUSIONS

The new metrics demonstrated high completion rates and their potential to track quality improvement efforts over time. They identified suboptimal treatment reach, but a potential increase in treatment over time and greater treatment among tobacco-related versus nontobacco-related cancers.

IMPACT

Continued tobacco use worsens cancer care outcomes. Integrating measures into cancer registries is a viable option for tracking tobacco treatment and cessation in the context of cancer care.

Qualitative evaluation of the implementation and future sustainability of an e-referral system for smoking cessation at a US NCI-designated comprehensive cancer center: lessons learned

BACKGROUND

Promoting smoking cessation is recognized as an essential part of cancer care. Moffitt Cancer Center, supported by the National Cancer Institute Cancer Moonshot Cancer Center Cessation Initiative, developed and implemented an opt-out-based automatic electronic health record (EHR)-mediated referral (e-referral) system for Tobacco Quitline services along with options for local group cessation support and an in-house tobacco treatment specialist. This study evaluated barriers and facilitators for implementation of the e-referral system.

METHOD

Steering committee members (N=12) responsible for developing and implementing the new clinical workflow and nurses (N=12) who were expected to use the new e-referral system completed semi-structured interviews. Qualitative thematic content analyses were conducted.

RESULTS

Interviewees perceived the e-referral system as an effective strategy for identifying and referring smokers to cessation services. However, barriers were noted including competing demands and perceptions that smoking cessation was a low priority and that some patients were likely to have low motivation to quit smoking. Suggestions to improve future implementation and sustainability included providing regular trainings and e-referral outcome reports and increasing the visibility of the e-referral system within the EHR.

CONCLUSION

Initial implementation of the e-referral system was perceived as successful; however, additional implementation strategies are needed to ensure sustainability at both the clinician and system levels. Recommendations for future modifications include providing regular clinician trainings and developing a fully closed-loop system. Implications for cancer survivors Initial implementation of an e-referral system for smoking cessation for cancer patients revealed opportunities to improve the smoking cessation referral process at cancer centers.

Smoking cessation pharmacotherapy use during index hospital admission following cystectomy for bladder cancer: A retrospective cohort study

BACKGROUND

To identify gaps in urologic oncology quality and evidence-based smoking cessation care by assessing how often smoking cessation pharmacotherapy (SCP) is given in the inpatient setting following cystectomy.

METHODS

The Premier Healthcare Database (PHD), a deidentified all-payer dataset, was used to generate nationally representative estimates of SCP receipt during hospitalization following cystectomy for patients with bladder cancer who smoke. Regressions were used to model associations between SCP receipt and patient- and hospital-level factors.

RESULTS

Of the 21,624 patients who underwent cystectomy for bladder cancer, 3,676 patients (17.0%) were identified as current smokers, representing a weighted estimate of 16,063 admissions. Among these admissions, 27.9% of patients received SCP, the vast majority of which (91.5%) received exclusively nicotine replacement therapy. Rates of SCP receipt varied substantially across hospitals (median: 25.0%, IQR: 20.0-33.3, range: 0.0-60.0). Older age and black race (aOR = 0.59, 95% CI: 0.42-0.82) were associated with lower odds of SCP receipt. Increased patient comorbidity score was associated with higher odds of SCP receipt (aOR = 1.02, 95% CI: 1.01-1.03); specifically, chronic pulmonary disease, alcohol abuse, and depression were independently associated with SCP receipt. Hospital teaching status, bed capacity, and mean annual cystectomy volume were not associated with SCP receipt. SCP receipt was not associated with hospital length of stay nor 90-day readmission or mortality following cystectomy.

CONCLUSIONS

SCP is infrequently given to patients who smoke during their hospitalization following cystectomy for bladder cancer, representing a gap in quality urologic oncology care and a missed opportunity to effectively intervene with evidence-based treatment.

The Impact of the COVID-19 Pandemic on Tobacco Treatment Program Implementation at National Cancer Institute-Designated Cancer Centers

INTRODUCTION

The COVID-19 pandemic disrupted cancer screening and treatment delivery, but COVID-19's impact on tobacco cessation treatment for cancer patients who smoke has not been widely explored.

AIMS AND METHODS

We conducted a sequential cross-sectional analysis of data collected from 34 National Cancer Institute (NCI)-designated cancer centers participating in NCI's Cancer Center Cessation Initiative (C3I), across three reporting periods: one prior to COVID-19 (January-June 2019) and two during the pandemic (January-June 2020, January-June 2021). Using McNemar's Test of Homogeneity, we assessed changes in services offered and implementation activities over time.

RESULTS

The proportion of centers offering remote treatment services increased each year for Quitline referrals (56%, 68%, and 91%; p = .000), telephone counseling (59%, 79%, and 94%; p = .002), and referrals to Smokefree TXT (27%, 47%, and 56%; p = .006). Centers offering video-based counseling increased from 2020 to 2021 (18% to 59%; p = .006), Fewer than 10% of centers reported laying off tobacco treatment staff. Compared to early 2020, in 2021 C3I centers reported improvements in their ability to maintain staff and clinician morale, refer to external treatment services, train providers to deliver tobacco treatment, and modify clinical workflows.

CONCLUSIONS

The COVID-19 pandemic necessitated a rapid transition to new telehealth program delivery of tobacco treatment for patients with cancer. C3I cancer centers adjusted rapidly to challenges presented by the pandemic, with improvements reported in staff morale and ability to train providers, refer patients to tobacco treatment, and modify clinical workflows. These factors enabled C3I centers to sustain evidence-based tobacco treatment implementation during and beyond the COVID-19 pandemic.

IMPLICATIONS

This work describes how NCI-designated cancer centers participating in the Cancer Center Cessation Initiative (C3I) adapted to challenges to sustain evidence-based tobacco use treatment programs during the COVID-19 pandemic. This work offers a model for resilience and rapid transition to remote tobacco treatment services delivery and proposes a policy and research agenda for telehealth services as an approach to sustaining evidence-based tobacco treatment programs.

Integrating Tobacco Treatment Into Oncology Care: Reach and Effectiveness of Evidence-Based Tobacco Treatment Across National Cancer Institute-Designated Cancer Centers

PURPOSE

Quitting smoking improves patients' clinical outcomes, yet smoking is not commonly addressed as part of cancer care. The Cancer Center Cessation Initiative (C3I) supports National Cancer Institute-designated cancer centers to integrate tobacco treatment programs (TTPs) into routine cancer care. C3I centers vary in size, implementation strategies used, and treatment approaches. We examined associations of these contextual factors with treatment reach and smoking cessation effectiveness.

METHODS

This cross-sectional study used survey data from 28 C3I centers that reported tobacco treatment data during the first 6 months of 2021. Primary outcomes of interest were treatment reach (reach)-the proportion of patients identified as currently smoking who received at least one evidence-based tobacco treatment component (eg, counseling and pharmacotherapy)-and smoking cessation effectiveness (effectiveness)-the proportion of patients reporting 7-day point prevalence abstinence at 6-month follow-up. Center-level differences in reach and effectiveness were examined by center characteristics, implementation strategies, and tobacco treatment components.

RESULTS

Of the total 692,662 unique patients seen, 44,437 reported current smoking. Across centers, a median of 96% of patients were screened for tobacco use, median smoking prevalence was 7.4%, median reach was 15.4%, and median effectiveness was 18.4%. Center-level characteristics associated with higher reach included higher smoking prevalence, use of center-wide TTP, and lower patient-to-tobacco treatment specialist ratio. Higher effectiveness was observed at centers that served a larger overall population and population of patients who smoke, reported a higher smoking prevalence, and/or offered electronic health record referrals via a closed-loop system.

CONCLUSION

Whole-center TTP implementation among inpatients and outpatients, and increasing staff-to-patient ratios may improve TTP reach. Designating personnel with tobacco treatment expertise and resources to increase tobacco treatment dose or intensity may improve smoking cessation effectiveness.

Treating Smoking in Cancer Patients: An Essential Component of Cancer Care-The New National Cancer Institute Tobacco Control Monograph

PURPOSE

Continued smoking after the diagnosis of cancer can markedly worsen oncology treatment side effects, cancer outcomes, cancer mortality, and all-cause mortality. Conversely, mounting evidence demonstrates that smoking cessation by patients with cancer improves outcomes. A cancer diagnosis often serves as a teachable moment, characterized by high motivation to quit. However, too few patients with cancer who smoke are offered evidence-based smoking cessation treatment, and too few engage in such treatment.

METHODS AND MATERIALS

The National Cancer Institute commissioned Tobacco Control Monograph 23, Treating Smoking in Cancer Patients: An Essential Component of Cancer Care, to review and synthesize the evidence that clarifies the need to intervene with smoking in cancer care.

RESULTS

Although many patients with newly diagnosed cancer who smoke make quit attempts, many of these are unsuccessful, and among those who successfully quit, relapse is common. Indeed, an estimated 12.2% of adults ever diagnosed with cancer reported they currently smoked (National Health Interview Survey, 2020). Patients with cancer who smoke are likely to benefit from smoking cessation treatments, including counseling and US Food and Drug Administration-approved medications, and there are many effective strategies to increase delivery of smoking cessation treatment in cancer care settings.

CONCLUSION

Smoking cessation is among the most effective treatment options for improving the likelihood of survival, quality of life, and overall health of patients with cancer who smoke. It is important for cancer care clinicians and patients to realize that it is never too late to quit smoking and that there are clear benefits to doing so, regardless of cancer type.

Proposing a Model of Proactive Outreach to Advance Clinical Research and Care Delivery for Patients Who Use Tobacco

There are evidence-based treatments for tobacco dependence, but inequities exist in the access to and reach of these treatments. Traditional models of tobacco treatment delivery are "reactive" and typically provide treatment only to patients who are highly motivated to quit and seek out tobacco treatment. Newer models involve "proactive" outreach, with benefits that include increasing access to tobacco treatment, prompting quit attempts among patients with low motivation, addressing health disparities, and improving population-level quit rates. However, the definition of "proactive" is not clear, and adoption has been slow. This commentary introduces a comprehensive yet flexible model of proactive outreach and describes how proactive outreach can optimize clinical research and care delivery in these domains: (1) identifying the population, (2) offering treatment, and (3) delivering treatment. Dimensions relevant to each domain are the intensity of proactive outreach (low to high) and the extent to which proactive outreach activities rely on human interaction or are facilitated by information technology (IT). Adoption of the proposed proactive outreach model could improve the precision and rigor with which tobacco cessation research and tobacco treatment programs report data, which could have a positive effect on care delivery and patient outcomes.

Operationalizing Leadership and Clinician Buy-In to Implement Evidence-Based Tobacco Treatment Programs in Routine Oncology Care: A Mixed-Method Study of the U.S. Cancer Center Cessation Initiative

BACKGROUND

Delivering evidence-based tobacco dependence treatment in oncology settings improves smoking abstinence and cancer outcomes. Leadership engagement/buy-in is critical for implementation success, but few studies have defined buy-in or described how to secure buy-in for tobacco treatment programs (TTPs) in cancer care. This study examines buy-in during the establishment of tobacco treatment programs at National Cancer Institute (NCI)-designated cancer centers.

METHODS

We utilized a sequential, explanatory mixed-methods approach to analyze quantitative data and qualitative interviews with program leads in the U.S.-based NCI Moonshot-supported Cancer Center Cessation Initiative (n = 20 Centers). We calculated descriptive statistics and applied structural coding and content analysis to qualitative data.

RESULTS

At least 75% of participating centers secured health care system administrative, clinical, and IT leadership buy-in and support. Six themes emerged from interviews: engaging leadership, access to resources, leveraging federal funding support to build leadership interest, designating champions, identifying training needs, and ensuring staff roles and IT systems support workflows.

CONCLUSIONS

Buy-in among staff and clinicians is defined by the belief that the TTP is necessary, valuable, and evidence based. Recognizing and securing these dimensions of buy-in can facilitate implementation success, leading to improved cancer outcomes.

Reach and effectiveness of the NCI Cancer Moonshot-funded Cancer Center Cessation Initiative

Smoking cessation results in improved cancer treatment outcomes. However, the factors associated with successful implementation of cessation programs in cancer care settings are not well understood. This paper presents the reach the reach and effectiveness of cessation programs implemented in NCI-Designated Cancer Centers in the Cancer Center Cessation Initiative (C3I). An observational, cross-sectional study was conducted among C3I Cancer Centers from July 1, 2019 and December 31, 2019 (N = 38). Reach was calculated as the proportion of patients reporting current smoking that received cessation treatment and was analyzed overall and by organizational characteristics. Smoking abstinence rates were determined by the proportion of participants self-reporting smoking abstinence in the previous 7 and 30 days at 6 months after treatment. On average, nearly 30% of patients who smoked received any cessation treatment. In-person counseling was most implemented but reached an average of only 13.2% of patients who smoked. Although less frequently implemented, average reach was highest for counseling provided via an interactive voice response system (55.8%) and telephone-based counseling (18.7%). Reach was higher at centers with more established programs, electronic health record referral systems, and higher smoking prevalence. At 6-month follow-up, about a fifth of participants on average had not smoked in the past 7 days (21.7%) or past 30 days (18.6%). Variations in reach by organizational characteristics suggest that leadership engagement and investment in technology-facilitated programs may yield higher levels of reach. Understanding which implementation and intervention strategies facilitate greater cessation treatment reach and effectiveness could lead to improved outcomes among cancer patients who smoke.

Demographic and Clinical Predictors of Engaging in Tobacco Cessation Counseling at a Comprehensive Cancer Center

PURPOSE

To address challenges promoting tobacco cessation in oncology settings, it is important to understand characteristics associated with patient engagement in tobacco cessation treatment. This analysis examined predictors of participating in at least one tobacco cessation counseling session among patients referred to a comprehensive cancer center's Tobacco Intervention and Psychosocial Support (TIPS) service.

METHODS

Patients with cancer who reported current smoking or recently quitting and referred to TIPS between June 2017 and February 2020 were included in the analysis. Independent variables included sex, race and ethnicity, insurance type, cancer diagnosis (tobacco-related or not), age, nicotine dependence, and cigarettes smoked per day at baseline. The outcome variable was completion of at least one tobacco cessation counseling session among those assessed by the TIPS program. Unadjusted and adjusted analyses tested associations between the independent variables and tobacco cessation counseling engagement.

RESULTS

Of 360 oncology patients referred to the TIPS program, 224 (62.2%) were assessed and 120 (33%) engaged in at least one counseling session. After controlling for sociodemographics and tobacco use, the results demonstrated that patients diagnosed with tobacco-related cancers were 45.3% less likely to engage in the tobacco cessation program compared with those with non-tobacco-related cancers (P = .041).

CONCLUSION

Patients diagnosed with tobacco-related cancers were less likely to engage in TIPS. Additional therapeutic resources may be needed to engage these patients to address potential explanatory factors, such as stigma, guilt, and fatalism. More research is needed to explore the impact of a tobacco-related cancer diagnosis on treatment engagement.

Using a multilevel implementation strategy to facilitate the screening and treatment of tobacco use in the outpatient urology clinic: A prospective hybrid type I study

BACKGROUND

Urologists frequently treat patients for tobacco-related conditions but infrequently engage in evidence-based practices (EBPs) that screen for and treat tobacco use. Improving the use of EBPs will help to identify smokers, promote cessation, and improve patients' health outcomes.

METHODS

A prospective type I hybrid effectiveness-implementation study was performed to test the feasibility and effectiveness of using a multilevel implementation strategy to improve the use of tobacco EBPs. All urology providers at outpatient urology clinics within the Veterans Health Administration Greater Los Angeles and all patients presenting for a new urology consultation were included. The primary outcome was whether a patient was screened for tobacco use at the time of consultation. Secondary outcomes included a patient's willingness to quit, chosen quit strategy, and subsequent engagement in quit attempts.

RESULTS

In total, 5706 consecutive veterans were seen for a new consultation during the 30-month study period. Thirty-six percent of all visits were for a tobacco-related urologic diagnosis. The percentage of visits that included tobacco use screening increased from 18% (before implementation) to 57% in the implementation phase and to 60% during the maintenance phase. There was significant provider-level variation in adherence to screening. Of all screened patients, 38% were willing to quit, and most patients chose a "cold turkey" method; 22% of the patients elected referral to a formal smoking cessation clinic, and 24% chose telephone counseling. Among those willing to quit, 39% and 49% made a formal quit attempt by 3 and 6 months, respectively.

CONCLUSIONS

A strategy that includes provider education and a customized clinical decision support tool can facilitate provider use of tobacco EBPs in a surgery subspecialty clinic.

Sustainability of Tobacco Treatment Programs in the Cancer Center Cessation Initiative

The NCI's Cancer Center Cessation Initiative (C3I) has a specific objective of helping cancer centers develop and implement sustainable programs to routinely address tobacco cessation with patients. Sustaining tobacco treatment programs requires the maintenance of (1) core program components, (2) ongoing implementation strategies, and (3) program outcomes evaluation. NCI funding of C3I included a commitment of resources toward sustainability. This article presents case studies to illustrate key strategies in developing sustainability capacity across 4 C3I-funded sites. Case studies are organized according to the domains of sustainability capacity defined in the Clinical Sustainability Assessment Tool (CSAT). We also describe the C3I Sustainability Working Group agenda to make scientific and practical contributions in 3 areas: (1) demonstrating the value of tobacco use treatment in cancer care, (2) identifying implementation strategies to support sustainability, and (3) providing evidence to inform policy changes that support the prioritization and financing of tobacco use treatment. By advancing this agenda, the Sustainability Working Group can play an active role in advancing and disseminating knowledge for tobacco treatment program sustainability to assist cancer care organizations in addressing tobacco use by patients with cancer within and beyond C3I.