Association of a Comprehensive Smoking Cessation Program With Smoking Abstinence Among Patients With Cancer

Refining Surveillance Guidelines after Stereotactic Body Radiation Therapy for Early-Stage Lung Cancer

INTRODUCTION

Stereotactic body radiation therapy (SBRT) is a treatment for patients with early-stage non-small cell lung cancer (ES-NSCLC). Surveillance guidelines vary after treatment. While patients are more likely to locally recur within 2 years of treatment, there remains a paucity of data on the benefit of frequent and long-term surveillance. We evaluated a cohort of NSCLC patients to evaluate surveillance patterns and outcomes.

MATERIALS AND METHODS

Patients with ES-NSCLC treated with SBRT were retrospectively evaluated. Imaging was reviewed after SBRT for evidence of recurrence or new malignancy. The median scan interval (MSI) was calculated as the median number of months between surveillance scans. The MSI between patients with or without new disease was compared by t-test. New disease development and survival between patients with =T2 disease and with or without prior malignancy was compared using χ², Kaplan-Meier analysis, and Gray's test.

RESULTS

A cohort of 168 patients with median follow up of 23.4 months met criteria for review with 50% developing new disease. MSI did not differ between patients with or without new disease. Patients with >=cT2 tumors had worse overall survival and trended towards higher incidence of new disease. New disease continued to occur, even 5 years after treatment.

CONCLUSION

Increased scan frequency did not increase detection of new disease. Patients continued to fail 5 years after treatment. Larger tumors trended toward more frequent failures and those patients experienced worse OS. Surveillance guidelines should be optimized to prevent over surveillance after treatment and to continue long-term surveillance.

Examining the Association between Abstinence from Smoking and Healthcare Costs among Patients with Cancer

Continuous tobacco use in patients with cancer is linked to substantial healthcare costs due to increased risks and complications, whereas quitting smoking leads to improved treatment outcomes and cost reductions. Addressing the need for empirical evidence on the economic impact of smoking cessation, this study examined the association between smoking cessation and healthcare cost utilization among a sample of 930 patients with cancer treated at The University of Texas MD Anderson Cancer Center's Tobacco Research and Treatment Program (TRTP). Applying conditional quantile regression and propensity scores to address confounding, our findings revealed that abstinence achieved through the TRTP significantly reduced the median cost during a 3-month period post-quitting by $1,095 [β = -$1,095, P = 0.007, 95% confidence interval (CI), = (-$1,886 to -$304)]. Sensitivity analysis corroborated these conclusions, showing a pronounced cost reduction when outlier data were excluded. The long-term accrued cost savings from smoking cessation could potentially offset the cost of participation in the TRTP program, underscoring its cost effectiveness. An important implication of this study is that by reducing smoking rates, healthcare systems can more efficiently allocate resources, enhance patient health outcomes, and lessen the overall cancer burden.

PREVENTION RELEVANCE

This study emphasizes the dual impact of smoking cessation programs in patients with cancer: quitting smoking and reducing healthcare costs. It highlights the importance of integrating cessation programs into cancer prevention strategies, ensuring both individual health benefits and broader, system-wide economic efficiencies. See related Spotlight, p. 197.

The effectiveness of smoking cessation interventions after cancer diagnosis: A systematic review and meta-analysis

OBJECTIVES

patients with cancer who smoke have more side effects during and after treatment, and a lower survival rate than patients with cancer who quit smoking. Supporting patients with cancer to quit smoking should be standard care. The aim of this systematic review was to determine the most effective smoking cessation method for patients diagnosed with cancer.

METHODS

PubMed, Embase, Web of Science and Google Scholar were systematically searched. Included were randomized controlled trials and observational studies published after January 2000 with any smoking cessation intervention in patients with any type of cancer. Result of these studies were evaluated in a meta-analysis.

RESULTS

A total of 18,780 papers were retrieved. After duplicate removal and exclusion based on title and abstract, 72 publications were left. After full text screening, 19 (randomized) controlled trials and 20 observational studies were included. The overall methodological quality of the included studies, rated by GRADE criteria, was very low. Two out of 21 combined intervention trials showed a statistical significant effect. Meta-analysis of 18 RCTs and 3 observational studies showed a significant benefit of combined modality interventions (OR 1.67, 95% C.I.: 1.24-2.26, p = 0.0008) and behavioural interventions (OR 1.33, 95% C.I.: 1.02 - 1.74, p = 0.03), but not for single modality pharmacological interventions (OR 1.11; 95% C.I.: 0.69-1.78, p = 0.66).

CONCLUSION

A combination of pharmacological and behavioural interventions may be the most effective intervention for smoking cessation in patients with cancer.

Associations of online health information seeking with health behaviors of cancer survivors

Objective

To examine the effects of online health information seeking (OHIS) behavior on five health behaviors (regular physical activity, less sedentary, calorie checking, no alcohol consumption, and no smoking) among adult cancer survivors in the United States.

Methods

A cross-sectional analysis was conducted with adult cancer survivors (≥18 years old) from Cycles 2, 3, and 4 of the Health Information National Trends Survey (HINTS). The respondents self-reported OHIS, and the data on the five health behaviors were pooled to perform descriptive and multivariable logistic regression analyses using Stata 17.0.

Results

Of the 1245 adult cancer survivors, approximately 74% reported OHIS behavior for themselves within the previous year of the survey. We found that OHIS was significantly and positively associated with the level of physical activity (odds ratio [OR] = 1.53, p = .002) and calorie checking (OR = 1.64, p = .001), but not with sedentary behavior, smoking, and alcohol consumption after adjusting for age, sex, race/ethnicity, education, income, body mass index (BMI), marital status, depression, and general health.

Conclusions

Findings from this study suggest that most cancer survivors used various forms of digital tools and platforms to seek health information. The study also demonstrated an independent impact of OHIS behavior on physical activity and calorie checking. Healthcare professionals may need to encourage and guide cancer survivors to seek credible eHealth information and further utilize digital health tools as a platform for care delivery, promoting health behaviors and preventing adverse health outcomes among cancer survivors.

Quitting smoking improves two-year survival after a diagnosis of non-small cell lung cancer

BACKGROUND

Smoking at diagnosis is associated with worse survival in lung cancer but the effects of quitting smoking on survival remain unclear.

METHODS

In a UK multi-centre study (NCT01192256) we followed all 2751 patients with newly diagnosed non-small cell lung cancer (NSCLC) for up to 2 years or until death as part of the observational trial. Patients were offered smoking cessation advice and treatments according to national guidelines and local services. Smoking status was verified by exhaled carbon monoxide levels. Kaplan-Meier survival analysis and Cox Proportional Hazards Modelling examined the effects of quitting smoking on survival at 2 years.

FINDINGS

646 were current smokers at the time of diagnosis. The unadjusted two-year Kaplan-Meier survivor functions for quitters (0.45, 95 %CI 0.37 to 0.53) and continuers (0.32, 0.28 to 0.36) were significantly different (log-rank test p < 0.01). Median survival times were 659 days for quitters and 348 days for continuers. After adjusting for age, sex, stage, performance status, curative intent surgery, radical radiotherapy and comorbidity, the hazard ratio for quitting at diagnosis (0.75, 95 % CI 0.58 to 0.98) indicated a statistically significant reduction in the risk of death across the two-year study period.

INTERPRETATION

Quitting smoking is independently and significantly associated with improved survival regardless of stage in NSCLC. We recommend that smoking cessation advice and treatments should be offered to smokers with lung cancer.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT01192256.

FUNDING

This work was supported by a 2010 Global Research Award for Nicotine Dependence (GRAND), Pfizer.

Smoking cessation interventions in patients diagnosed with head and neck cancers: A systematic review of randomized controlled trials

Objective

According to findings from the previous studies, quitting smoking can significantly reduce mortality from all causes and is linked to better treatment results. Even though quitting smoking has many benefits, little is known about the evidence supporting the particular quit services offered to smokers after a cancer diagnosis.

Methods

To find the articles related to area in question, different electronic databases including PubMed/Medline, Google Scholar, and EBSCO were searched on April 1st, 2023. All full text randomized controlled trials with one or more intervention and control groups that assessed the outcomes of smoking cessation interventions were included. Participants of included studies were adults diagnosed with head and neck cancer (HNC) and current smokers or those who had recently quit. There were interventions (pharmacological and/or pharmacological) that aimed to help patients with HNC succeed in quitting smoking.

Results

We identified 15352 papers from the initial search from different electronic databases, 2560 remained after excluding duplicates. After screening titles and abstracts for relevance, 2345 articles were removed. Full text articles of remaining 215 papers were assessed in depth by two reviewers for their eligibility, amongst which, 210 articles were excluded. Finally, we included five papers that met the inclusion criteria in the present systematic review.

Conclusion

According to the findings of this review, a multi - component strategy might very well benefit patients with HNC who smoke cigarettes after diagnosis. More studies with high methodological quality and standardized outcome measures must be conducted in this population to inform the development of smoking cessation program.

Implementation planning for equitable tobacco treatment services: a mixed methods assessment of contextual facilitators and barriers in a large comprehensive cancer center

Tobacco use among cancer patients is associated with an increased mortality and poorer outcomes, yet two-thirds of patients continue using following diagnosis, with disproportionately higher use among racial/ethnic minority and low socioeconomic status patients. Tobacco treatment services that are effectively tailored and adapted to population characteristics and multilevel context specific to settings serving diverse patients are needed to improve tobacco cessation among cancer patients. We examined tobacco use screening and implementation needs for tobacco treatment services to inform equitable and accessible delivery within a large comprehensive cancer center in the greater Los Angeles region. We conducted a multi-modal, mixed methods assessment using electronic medical records (EMR), and clinic stakeholder surveys and interviews (guided by the Consolidated Framework for Implementation Research). Approximately 45% of patients (n = 11,827 of 26,030 total) had missing tobacco use history in their EMR. Several demographic characteristics (gender, age, race/ethnicity, insurance) were associated with greater missing data prevalence. In surveys (n = 32), clinic stakeholders endorsed tobacco screening and cessation services, but indicated necessary improvements for screening/referral procedures. During interviews (n = 13), providers/staff reported tobacco screening was important, but level of priority differed as well as how often and who should screen. Several barriers were noted, including patients' language/cultural barriers, limited time during visits, lack of smoking cessation training, and insurance coverage. While stakeholders indicated high interest in tobacco use assessment and cessation services, EMR and interview data revealed opportunities to improve tobacco use screening across patient groups. Implementing sustainable system-level tobacco cessation programs at institutions requires leadership support, staff training, on routine screening, and intervention and referral strategies that meet patients' linguistic/cultural needs.

Unveiling the Tapestry of Tobacco Consumption: Exploring the Sociodemographic Factors Impacting Smokers at Smoking Cessation Clinics in Jeddah

Background The World Health Organization (WHO) has identified tobacco smoking as a global epidemic, causing an estimated three million deaths annually. This study aims to examine the sociodemographic characteristics and smoking-related behaviors among individuals attending smoking cessation clinics in Jeddah during 2022. By identifying these factors, appropriate interventions can be developed to combat the smoking epidemic. Methodology The study enrolled male and female participants who visited the Smoking Cessation Clinics in Jeddah from January 2022 to December 2022. Eligible participants were between 18 and 60 years old and agreed to take part in the study. Data on smoking status, medical history, previous attempts at quitting, and medication use were collected. Statistical analysis, including chi-square tests and P-values, was conducted to assess the associations between participants' medical history and smoking cessation attempts. Results A total of 5,869 participants were included in the study. The findings revealed that approximately one-fifth of the participants had previously attempted to quit smoking, while the majority 4,780 (81.4%) had not made any cessation attempts. Among those who had made quit attempts, the majority had tried quitting between one and four times 968 (16.5%). The duration of successful cessation reported by participants was generally short, with the majority 4,781 (81.5%) not experiencing any extended period of quitting. Common reasons for relapse included cravings, social influences, mood changes, stress, and withdrawal symptoms. The study also found significant associations between specific medical conditions and smoking cessation attempts. Conclusions The study identified significant associations between male gender, older age group (51-60 years), divorced marital status, intermediate educational levels, higher income levels, retired status, extreme body mass index (BMI) categories, and previous attempts at smoking cessation. Healthcare providers and policymakers should consider these findings when developing and implementing smoking cessation programs. The insights gained from this research can contribute to the development of targeted interventions to reduce smoking rates and improve public health outcomes.

The gold standard program (GSP) for smoking cessation: a cohort study of its effectiveness among smokers with and without cancer

BACKGROUND

Smoking cessation treatment is an important prognostic factor for survival after a cancer diagnosis, especially for tobacco-related cancers. After being diagnosed with lung cancer, approximately 50% of patients continue smoking or frequently relapse after a quit attempt. Given the importance of smoking cessation treatment for cancer survivors, the objective was to compare the effectiveness of a 6-week intensive smoking cessation intervention, the Gold Standard Program (GSP), among cancer survivors compared with smokers without cancer. Second, we compared successful quitting among socioeconomically disadvantaged cancer survivors with that among nondisadvantaged cancer survivors.

MATERIALS AND METHODS

This was a cohort study based on 38,345 smokers from the Danish Smoking Cessation Database (2006-2016). Linkage to the National Patient Register was used to identify cancer survivors undergoing the GSP after being diagnosed with cancer (except nonmelanoma skin cancer). Linkage to the Danish Civil Registration System was used to identify participants who died, went missing, or emigrated before the follow-up. Logistic regression models were applied to evaluate effectiveness.

RESULTS AND CONCLUSION

Six percent (2438) of the included smokers were cancer survivors at the time they undertook the GSP. Their 6-month successful quitting showed no difference compared to that of smokers without cancer, neither before nor after adjustment; 35% versus 37% in crude rates and an aOR of 1.13 (95% CI: 0.97-1.32). Likewise, the results for disadvantaged compared to nondisadvantaged cancer survivors were not significantly different (32% versus 33% and an adjusted aOR of 0.87 (95% CI 0.69-1.11)). Overall, an intensive smoking cessation program seems effective in helping both people without cancer and cancer survivors become successful quitters.

Cancer trends and risk factors in China over the past 30 years (1990-2019)

Objective: We retrospectively studied cancer mortality and incidence in China from 1990 to 2019, investigated the cancer trends and risk factors, and analyzed the effects of Gross Domestic Product (GDP) on cancer mortality and incidence. Methods: Data was obtained in "Our world in data" in October 2022 to explore mortality rates of different cancers and their trends and the roles of cancer risk factors, including GDP, air pollution, etc. Results: Over the past 30 years, cancer had been China's second leading cause of death. Tracheal, bronchial, and lung cancers, with an annual growth rate of 6.5%, were the most frequently diagnosed cancers. The burden of different cancers changed as the mortality rate of cancer changed. The age-standardized cancer mortality rate had decreased by 19.0%; cancer deaths in all age groups had increased. While the number of cancer deaths in the elderly aged ≥70 did not increase distinctively, its percentage increased by 52.1% and 1.7% annually. The percentage of patients with new-onset cancer increased by 240% and 8.6% annually. For every USD 1,000 increase in GDP, cancer deaths decreased by 2.3/100,000. Tobacco, meat, and alcohol consumption and BMI had increased and were not conducive to the future control of cancer. Conclusions: We summarized the incidence and mortality of major cancers and their trends in China over the past 30 years and analyzed the effects of GDP and the roles of cancer risk factors. Overall GDP growth and effective control of air pollution reduced cancer mortality, while population aging, smoking, alcohol consumption, BMI increasing, and meat consumption brought challenges for cancer control.

Effective Timing of Introducing an Inpatient Smoking Cessation Program to Cancer Patients

PURPOSE

We aimed to identify factors influencing smoking cessation success among cancer patients registered in an inpatient smoking cessation program at a single cancer center.

MATERIALS AND METHODS

The electronic medical records of enrolled patients with solid cancer were retrospectively reviewed. We evaluated factors associated with 6-month smoking cessation.

RESULTS

A total of 458 patients with cancer were included in this study. Their mean age was 62.9±10.3 years, and 56.3% of the participants had lung cancer. 193 (42.1%) had not yet begun their main treatment. The mean number of counseling sessions for the participants was 8.4±3.5, and 46 (10.0%) patients were prescribed smoking cessation medications. The 6-month smoking cessation success rate was 48.0%. Multivariate analysis showed that younger age (<65 years), cohabited status, early stage, and the number of counseling sessions were statistically significant factors affecting 6-month smoking cessation success (p<0.05). Initiation of a cessation program before cancer treatment was significantly associated with cessation success (odds ratio, 1.66; 95% confidence interval, 1.02-2.70; p=0.040).

CONCLUSION

Smoking cessation intervention must be considered when establishing a treatment plan immediately after a cancer diagnosis among smokers.

Smoking Cessation and Tobacco-related Risk Perceptions among People with and without a Diagnosis of Cancer

BACKGROUND

Little is known about how cancer diagnosis and tobacco-related risk perceptions are associated with smoking behavior.

METHODS

We used data from Waves (W) 1-3 (2013-2016) of the Population Assessment of Tobacco and Health Study to analyze longitudinal smoking behavior among adults who were current smokers and not previously diagnosed with cancer at baseline (W1; N = 7,829). The outcome was smoking cessation as of follow-up (W3). Explanatory variables were sociodemographics, other tobacco product use, adult at first cigarette, tobacco dependence, cancer diagnosis after baseline, and tobacco-related risk perceptions [cigarette harm perception, worry that tobacco products will damage one's health ("worry"), belief that smoking causes cancer ("belief"), and nondaily smoking harm perception].

RESULTS

Cessation was significantly associated with baseline worry (OR = 1.26; 95% confidence interval, 1.13-1.40), follow-up cigarette harm perception [OR = 2.01 (1.77-2.29)], and follow-up belief [OR = 1.40 (1.20-1.63)]. Cessation was inversely associated with follow-up (W3) worry, and this association was stronger among those without a cancer diagnosis (OR = 0.37 without cancer; OR = 0.76 among individuals diagnosed with cancer; interaction P = 0.001).

CONCLUSIONS

Cessation is associated with tobacco-related risk perceptions, with different perceptions contributing in unique ways. Cessation is predicted by baseline worry but is inversely associated with worry at follow-up, suggesting that perhaps cessation has alleviated worry. The latter finding was stronger among respondents not diagnosed with cancer.

IMPACT

Associations between cancer diagnosis, tobacco-related risk perceptions, and smoking behavior may inform the development of evidence-based smoking cessation interventions.

Developing a Collaborative, Team-Based Smoking Cessation Treatment Program in an Outpatient Oncology Setting

PURPOSE

Because clinical specialists often lack time and training to address secondary health issues such as smoking cessation, the National Cancer Institute Cancer Center Cessation Initiative (C3I) has mobilized cancer centers to develop systems for treating patients' tobacco dependence.

METHODS

One university-based cancer center was able to develop a program that formalized smoking treatment using a collaborative, multidisciplinary care team with overlapping expertise in cancer care, medication management, and tobacco cessation. Program planners delivered tobacco cessation services in the outpatient setting by automating identification of eligible patients using a tobacco registry in the electronic health records, directly involving oncology pharmacists in medication oversight, using dedicated tobacco treatment specialists to provide cessation services, and engaging oncologists through active communications protocols. Evaluators used Practical Robust Implementation and Sustainability Model as the guiding framework for a qualitative assessment of program development and implementation. Evaluators also measured provider satisfaction and utilization of services, program reach, and smoking cessation outcomes 6 months post enrollment.

RESULTS

During the evaluation period (July 1, 2018-September 30, 2019), the smoking cessation program engaged 96% of eligible patients (n = 214 of 223 eligible); 82% of those enrolled in the program (n = 183). At 6-month follow-up, 29.1% of enrolled patients self-reported 30-day point prevalence abstinence (n = 53) and 34.9% (n = 64) reported 7-day point prevalence abstinence (intent-to-treat rates).

CONCLUSION

Using a team-based approach that leverages individual expertise and interprofessional collaboration to provide patient-centered treatment, a smoking cessation program can identify and treat eligible patients in specialty clinics.

Systematic Review of Smoking Cessation Interventions for Smokers Diagnosed with Cancer

The detrimental impact of smoking on health and wellbeing are irrefutable. Additionally, smoking is associated with the development of cancer, a reduction treatment outcomes and poorer health outcomes. Nevertheless, a significant number of people continue to smoke following a cancer diagnosis. Little is understood of the smoking cessation services provided to smokers with cancer or their engagement with them. This systematic review aimed to identify existing smoking cessation interventions for this cohort diagnosed with breast, head and neck, lung and cervical cancers (linked to risk). Systematic searches of Pubmed, Embase, Psych Info and CINAHL from 1 January 2015 to 15 December 2020 were conducted. Included studies examined the characteristics of smoking cessation interventions and impact on referrals and quit attempts. The impact on healthcare professionals was included if reported. Included studies were restricted to adults with a cancer diagnosis and published in English. No restriction was placed on study designs, and narrative data synthesis was conducted due to heterogeneity. A review protocol was registered on PROSPERO CRD 42020214204, and reporting adheres to PRISMA reporting guidelines. Data were screened, extracted in duplicate and an assessment of the quality of evidence undertaken using Mixed Methods Assessment Tool. 23 studies met the inclusion criteria, representing USA, Canada, England, Lebanon, Australia and including randomized controlled trials (9), observational studies (10), quality improvement (3), and one qualitative study. Hospital and cancer clinics [including a dental clinic] were the settings for all studies. 43% (10/23) of studies reported interventions for smokers diagnosed with head and neck cancer, 13% (3/23) for smokers diagnosed with lung cancer, one study provides evidence for breast cancer, and the remaining nine studies (39%) report on multiple cancers including the ones specified in this review. Methodological quality was variable. There were limited data to identify one optimal intervention for this cohort. Key elements included the timing and frequency of quit conversations, use of electronic records, pharmacotherapy including extended use of varenicline, increased counselling sessions and a service embedded in oncology departments. More studies are required to ensure tailored smoking cessation pathways are co-developed for smokers with a diagnosis of cancer to support this population.

Changes in Cigarette Smoking Behavior in Cancer Survivors During Diagnosis and Treatment

INTRODUCTION

Continued cigarette smoking is a critical determinant of outcome in oncology patients, but how the separate events of cancer diagnosis, cancer treatment, and completion of treatment affect smoking behavior in cancer survivors is unknown. This study described such changes, hypothesizing that they would be more pronounced for smoking-related cancers.

METHODS

The Cancer Patient Tobacco Use Questionnaire (CTUQ) was sent to every cancer patient ≥ 18 y old scheduled for outpatient visits at the Mayo Clinic Cancer Center with a current or former history of tobacco use.

RESULTS

From September 2019 to September 2020, 33,831 patients received the CTUQ, and 20,818 (62%) responded. Of the 3007 current smokers analyzed, 34% quit at diagnosis; those with smoking-related cancers were more likely to quit (40% vs. 29%, respectively, p < .001). Among those who did not quit at diagnosis, 31% quit after starting cancer treatment, and those with smoking-related cancers were more likely to quit (35% and 28%, respectively, p = .002) Among those who had quit before the completion of treatment, 13% resumed smoking after treatment ended. In multivariable analysis, patients with smoking-related cancers were more likely to report 30-d point prevalence abstinence from pre-diagnosis to the completion of treatment (adjusted OR 1.98 [95% CI 1.65, 2.36], p < .001).

CONCLUSIONS

Both cancer diagnosis and treatment prompt smoking abstinence, with most maintaining abstinence after treatment is completed. Those with smoking-related cancers are more likely to quit. These results emphasize the need to provide access to tobacco treatment services that can further support cancer patients who smoke.

IMPLICATIONS

Approximately one-third of cancer patients who smoke quit smoking at the time of diagnosis, an additional one-third of patients who had not yet quit did so at the initiation of treatment, and most sustained this abstinence after treatment completion. Patients with smoking-related cancers are more likely to quit. Thus, there are multiple opportunities within the cancer care continuum to intervene and support quit attempts or continued abstinence.

Effect of Smoking on Treatment Efficacy and Toxicity in Patients with Cancer: A Systematic Review and Meta-Analysis

Simple Summary

The impact of smoking on cancer treatment efficacy and toxicity regardless of cancer type was investigated in this meta-analysis. Smoking during radiotherapy/chemoradiotherapy was associated with worse outcomes and a higher risk for toxicity. Smoking during treatment with EGFR tyrosine kinase inhibitors in lung cancer patients was associated with a worse prognosis, whereas smoking was associated with better outcomes in patients treated with checkpoint inhibitors. No association between smoking and treatment efficacy of chemotherapy was observed, though with low certainty of evidence. Our results can be used by oncology and radiotherapy staff to give patients more convincing information on the benefits that can be derived from smoking cessation before cancer treatment.

Abstract

Aim: The aim of the present systematic review and meta-analysis was to summarize the current evidence on the potential impact of smoking during cancer treatment on treatment efficacy and toxicity irrespective of cancer type. Methods: A systematic literature search was performed using two electronic databases for potentially eligible studies. Only studies based on multivariable analysis for the association between smoking, compared to non-smokers (never or former), and treatment efficacy or toxicity were included. Pooled Hazard Ratios (HRs) or Odds Ratios (ORs) and corresponding 95% Confidence Intervals (CIs) were estimated through random-effects meta-analyses. Results: In total, 97 eligible studies were identified, of which 79 were eligible for the pooled analyses. Smoking during radiation therapy, with or without chemotherapy, was associated with an increased risk of locoregional recurrence (pooled HR: 1.56; 95% CI: 1.28–1.91 for radiation therapy; pooled HR: 4.28; 95% CI: 2.06–8.90 for chemoradiotherapy) and worse disease-free survival (pooled HR: 1.88; 95% CI: 1.21–2.90 for radiation therapy; pooled HR: 1.92; 95% CI: 1.41–2.62 for chemoradiotherapy) as well as a higher risk for radiation-induced toxicity (pooled OR: 1.84; 95% CI: 1.32–2.56 for radiation therapy; pooled OR: 2.43; 95% CI: 1.43–4.07 for chemoradiotherapy) with low-to-moderate certainty of evidence. Smoking during treatment with EGFR tyrosine kinase inhibitors (EGFR-TKIs) in patients with lung cancer was associated with worse progression-free survival compared to non-smokers (pooled HR: 1.43; 95% CI: 1.14–1.80; moderate certainty of evidence), whereas smoking was associated with improved progression-free survival in patients treated with checkpoint inhibitors (HR: 0.70; 95% CI: 0.58–0.84; moderate certainty of evidence). No statistically significant associations were observed between smoking and treatment efficacy or toxicity to chemotherapy. Conclusion: The present meta-analysis confirms earlier evidence of the negative impact of smoking during radiation therapy, with or without chemotherapy, on treatment efficacy and radiation-induced toxicity as well as a negative impact of smoking on the efficacy of EGFR-TKIs and a positive impact on the efficacy of checkpoint inhibitors. The evidence is too weak to draw firm conclusions on the potential association between smoking and chemotherapy, whereas there is no evidence for pooled analyses regarding other types of systemic oncological therapy.

Smoking cessation by combined medication and counselling: a feasibility study in lung cancer patients

Purpose

Smoking cessation in patients with diagnosed lung cancer has positive effects on cancer therapy and overall prognosis. Despite this, knowledge on smoking cessation in lung cancer patients is sparse.

Methods

This is an observational single centre, 12-week, prospective, single-arm trial at a tertiary lung cancer centre. Responsive patients were enrolled following confirmed lung cancer diagnosis. Smoking cessation intervention included counselling as well as pharmacotherapy. The primary endpoint was the point prevalence abstinence rate at week 12 based on biochemical verification. Secondary endpoints were the abstinence rate at week 26, quality of life and side effects.

Results

80 patients were enrolled. Mean age was 62.6 ± 7.9 years. Most patients (63%) were treated with chemotherapy or radiochemotherapy. 39 patients used nicotine replacement therapy, 35 varenicline whereas six patients did not use pharmacotherapy. During the study period 13 patients died. Data were available in 72 patients after 12 weeks and 57 patients at week 24. Point prevalence abstinence rates were 37.5% (95% CI 26.4–49.7%) at week 12 and 32.8% (95% CI 21.8–45.4%) at week 26, respectively. Quality of life and side effects were not significantly affected by pharmacotherapy.

Conclusion

In conclusion, our results suggest that smoking cessation is feasible in patients with newly diagnosed lung cancer. The observed abstinence rate is comparable to other patient cohorts. Furthermore, pharmacotherapy in addition to cancer therapy was safe and did not show novel side effects in these seriously ill patients. Thus, smoking cessation should be an integral part of lung cancer treatment.

Trial registration The study was conducted in accordance with good clinical practice standards (GCP) and approved by the local ethics committee (16/3/14), the European PAS registry (EUPAS8748) and the German BfArM (NIS-Studien-Nr. 5508). All patients provided written informed consent before study enrollment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02048-1.

Increased Reach and Effectiveness With a Low-Burden Point-of-Care Tobacco Treatment Program in Cancer Clinics

BACKGROUND

Tobacco cessation after a cancer diagnosis can extend patient survival by improving outcomes for primary cancer and preventing secondary cancers. However, smoking is often unaddressed in cancer care, highlighting the need for strategies to increase treatment reach and cessation. This study examined a low-burden, point-of-care tobacco treatment program (ELEVATE) featuring an electronic health record-enabled smoking module and decision support tools to increase the reach and effectiveness of evidence-based smoking cessation treatment.

METHODS

This study included adult outpatient tobacco smokers (n=13,651) in medical oncology, internal medicine, and surgical oncology clinics from a large midwestern healthcare system. We examined reach and effectiveness of ELEVATE with 2 comparisons: (1) preimplementation versus postimplementation of ELEVATE and (2) ELEVATE versus usual care. Data were evaluated during 2 time periods: preimplementation (January through May 2018) and postimplementation (June through December 2018), with smoking cessation assessed at the last follow-up outpatient encounter during the 6 months after these periods.

RESULTS

The proportion of current tobacco smokers receiving cessation treatment increased from pre-ELEVATE to post-ELEVATE (1.6%-27.9%; difference, 26.3%; relative risk, 16.9 [95% CI, 9.8-29.2]; P<.001). Compared with 27.9% treatment reach with ELEVATE in the postimplementation time period, reach within usual care clinics ranged from 11.8% to 12.0% during this same period. The proportion of tobacco smokers who subsequently achieved cessation increased significantly from pre-ELEVATE to post-ELEVATE (12.0% vs 17.2%; difference, 5.2%; relative risk, 1.3 [95% CI, 1.1-1.5]; P=.002). Compared with 17.2% smoking cessation with ELEVATE in the postimplementation time period, achievement of cessation within usual care clinics ranged from 8.2% to 9.9% during this same period.

CONCLUSIONS

A low-burden, point-of-care tobacco treatment strategy increased tobacco treatment and cessation, thereby improving access to and the impact of evidence-based cessation treatment. Using implementation strategies to embed tobacco treatment in every healthcare encounter promises to engage more smokers in evidence-based treatment and facilitate smoking cessation, thereby improving care cancer for patients who smoke.

Bupropion XL and SR have similar effectiveness and adverse event profiles when used to treat smoking among patients at a comprehensive cancer center

BACKGROUND AND OBJECTIVES

Bupropion extended-release (XL; once-daily dosing) has equal efficacy with the sustained-release (SR) formulation (twice-daily dosing) for treating depression, but no studies have compared the two formulations for the treatment of smoking. In a naturalistic open-label study, we compared the effectiveness and the adverse event profiles of XL and SR in treating cancer patients for smoking.

METHODS

Cancer patients (N = 648) were prescribed bupropion XL (n = 454) or SR (n = 194) alone or in combination with nicotine replacement therapy (NRT) for treating smoking from September 2006 to December 2017. We analyzed 7-day point prevalence abstinence at end-of-treatment (EOT; 3 months postmedication initiation) and evaluated for noninferiority. We also analyzed the adverse event profile differences between the medications.

RESULTS

There were no significant differences in abstinent rates at EOT between bupropion XL and SR when using intent-to-treat models, regardless of concomitant NRT. XL demonstrated noninferiority in treatment efficacy compared to SR when excluding those on combined treatment with NRT. Further, there were no significant differences in spontaneously reported adverse events between XL and SR.

CONCLUSIONS

Our data did not reveal a difference between bupropion XL and SR formulations in terms of effectiveness or adverse event profiles among cancer patients prescribed bupropion alone or in combination with NRTs to quit smoking.

SCIENTIFIC SIGNIFICANCE

In this first published direct comparison of their effectiveness and adverse event profiles, we found that bupropion XL is likely therapeutically equivalent to bupropion SR when treating smoking among cancer patients, and produces similar side effects.

Smoking Cessation Training and Treatment: Options for Cancer Centres

Patients who achieve smoking cessation following a cancer diagnosis can experience an improvement in treatment response and lower morbidity and mortality compared to individuals who continue to smoke. It is therefore imperative for publicly funded cancer centres to provide appropriate training and education for healthcare providers (HCP) and treatment options to support smoking cessation for their patients. However, system-, practitioner-, and patient-level barriers exist that hamper the integration of evidence-based cessation programs within publicly funded cancer centres. The integration of evidence-based smoking cessation counselling and pharmacotherapy into cancer care facilities could have a significant effect on smoking cessation and cancer treatment outcomes. The purpose of this paper is to describe the elements of a learning health system for smoking cessation, implemented and scaled up in community settings that can be adapted for ambulatory cancer clinics. The core elements include appropriate workflows enabled by technology, thereby improving both practitioner and patient experience and effectively removing practitioner-level barriers to program implementation. Integrating the smoking cessation elements of this program from primary care to cancer centres could improve smoking cessation outcomes in patients attending cancer clinics.

Effectiveness, Cost-effectiveness, and Cost-Utility of a Digital Smoking Cessation Intervention for Cancer Survivors: Health Economic Evaluation and Outcomes of a Pragmatic Randomized Controlled Trial

Background

Smoking cessation (SC) interventions may contribute to better treatment outcomes and the general well-being of cancer survivors.

Objective

This study aims to evaluate the effectiveness, cost-effectiveness, and cost-utility of a digital interactive SC intervention compared with a noninteractive web-based information brochure for cancer survivors.

Methods

A health economic evaluation alongside a pragmatic 2-arm parallel-group randomized controlled trial was conducted with follow-ups at 3, 6, and 12 months. The study was conducted in the Netherlands over the internet from November 2016 to September 2019. The participants were Dutch adult smoking cancer survivors with the intention to quit smoking. In total, 165 participants were included and analyzed: 83 (50.3%) in the MyCourse group and 82 (49.7%) in the control group. In the intervention group, participants had access to a newly developed, digital, minimally guided SC intervention (MyCourse-Quit Smoking). Control group participants received a noninteractive web-based information brochure on SC. Both groups received unrestricted access to usual care. The primary outcome was self-reported 7-day smoking abstinence at the 6-month follow-up. Secondary outcomes were quality-adjusted life years gained, number of cigarettes smoked, nicotine dependence, and treatment satisfaction. For the health economic evaluation, intervention costs, health care costs, and costs stemming from productivity losses were assessed over a 12-month horizon.

Results

At the 6-month follow-up, the quit rates were 28% (23/83) and 26% (21/82) in the MyCourse and control groups, respectively (odds ratio 0.47, 95% CI 0.03-7.86; P=.60). In both groups, nicotine dependence scores were reduced at 12 months, and the number of smoked cigarettes was reduced by approximately half. The number of cigarettes decreased more over time, and the MyCourse group demonstrated a significantly greater reduction at the 12-month follow-up (incidence rate ratio 0.87; 95% CI 0.76-1.00; P=.04). Intervention costs were estimated at US $193 per participant for the MyCourse group and US $74 for the control group. The mean per-participant societal costs were US $25,329 (SD US $29,137) and US $21,836 (SD US $25,792), respectively. In the cost-utility analysis, MyCourse was not preferred over the control group from a societal perspective. With smoking behavior as the outcome, the MyCourse group led to marginally better results per reduced pack-year against higher societal costs, with a mean incremental cost-effectiveness ratio of US $52,067 (95% CI US $32,515-US $81,346).

Conclusions

At 6 months, there was no evidence of a differential effect on cessation rates; in both groups, approximately a quarter of the cancer survivors quit smoking and their number of cigarettes smoked was reduced by half. At 12 months, the MyCourse intervention led to a greater reduction in the number of smoked cigarettes, albeit at higher costs than for the control group. No evidence was found for a differential effect on quality-adjusted life years.

Trial Registration

The Netherlands Trial Register NTR6011; https://www.trialregister.nl/trial/5434

International Registered Report Identifier (IRRID)

RR2-10.1186/s12885-018-4206-z

The Impact of Treatment for Smoking on Breast Cancer Patients’ Survival

Simple Summary

This was a retrospective analysis of breast cancer patients who were self-identified as smokers at diagnosis and who were invited to participate in a comprehensive tobacco treatment program (TP) that provided pharmacotherapy and motivational counseling to quit smoking. Our study shows that quitting smoking is associated with improved survival among breast cancer patients who smoke across all tumor stages. In our survival analysis, tobacco abstainers were more likely than smokers to be alive with no evidence of disease (hazard ratio = 0.616 95%CI (0.402–0.945), p = 0.026). Comprehensive approach to address smoking cessation may prolong survival outcomes when started as early as the time of diagnosis.

Abstract

Background: Smoking negatively affects overall survival after successful breast cancer (BC) treatment. We hypothesized that smoking cessation would improve survival outcomes of BC patients who were smokers at the time of diagnosis. Methods: This was a retrospective analysis of self-identified smokers with BC treated at The University of Texas MD Anderson Cancer Center. Patient demographics, date of diagnosis, tumor stage, tobacco treatment program (TP) participation, and time to death were extracted from our departmental databases and institutional electronic health records. We examined associations between tobacco abstinence status and survival using survival models, with and without interactions, adjusted for personal characteristics and biomarkers of disease. Results: Among all 31,069 BC patients treated at MD Anderson between 2006 and 2017, we identified 2126 smokers (6.8%). From those 2126 self-identified smokers, 665 participated in the TP, reporting a conservative estimate of 31% abstinence (intent-to-treat) 9 months into the program. Patients without reported follow-up abstinence status (including TP and non-TP participants) were handled in the analyses as smokers. Survival analysis controlled for multiple factors, including disease characteristics and participation in the TP, indicated that abstainers were more likely to be alive with no evidence of disease compared to non-abstainers (HR, 0.593; 95% CI, 0.386–0.911; p = 0.017). Conclusion: Our results suggest that quitting smoking is associated with improved survival among BC patients who were smokers at time of diagnosis across all tumor stages. Comprehensive approaches for smoking cessation in patients diagnosed with BC may prolong survival when started as early as the time of diagnosis.

Training Tobacco Treatment Specialists through Virtual Asynchronous Learning

Tobacco dependence is a prevalent, chronic, and complex addiction that often leads to long-term disease and death. However, few healthcare providers are sufficiently trained and feel comfortable in delivering tobacco dependence treatment. The purpose of the study was to examine the effectiveness of an accredited online Tobacco Treatment Specialist (TTS) training program that uses a novel, asynchronous approach. We compared the characteristics of participants who completed the program to those who did not complete the program. Changes in knowledge and attitudes in providing tobacco dependence treatment were measured, and satisfaction with the program and intent to pursue national certification were assessed. Participants who were more likely to complete the program were those who discussed quitting less frequently with patients prior to course enrollment. These participants had a significant increase in knowledge and high satisfaction with the course. Approximately half of participants who completed the program indicated that they would pursue obtaining a national certificate in tobacco dependence treatment in the next 2 years.

Implementation and evaluation of a smoking cessation checklist implemented within Australian cancer services

Introduction

The detrimental impact of smoking tobacco can be mitigated when cancer patients quit smoking. Smoking cessation clinical pathways are inconsistently implemented within Australian cancer services. The aim of this study was to pilot test and evaluate the reach, adoption, and implementation of a smoking cessation checklist within oncology services.

Methods

The checklist was implemented over a 6‐month period in medical and radiation oncology services at two metropolitan and one rural hospital. The RE‐AIM framework guided the evaluation process. Implementation strategies included training, process mapping, and identifying champions. Evaluation measures included a clinical data audit, surveys, and semi‐structured interviews with healthcare professionals (HCPs).

Results

Healthcare professionals (HCPs; N = 63; 41% oncologists, 32% nurses, 27% others) completed 1276 checklists with cancer patients between November 2019 and December 2020. Of the 126 (10%) identified current smokers, 34 (27%) accepted a referral to either Quitline, Nicotine Replacement Therapy, to a general practitioner or dedicated HCP for follow‐up telephone support. There was variation in screening adoption by HCPs across the three hospitals, with 16%, 92% and 89.5% of patients screened respectively. Contextual factors, such as perceived commitment, role identity, and communication processes appeared to influence the outcomes.

Conclusion

A checklist is a simple, effective, and versatile intervention used to standardise smoking cessation practices in medical and radiation oncology services. The checklist supports standardisation of referral practices to smoking cessation services for cancer patients by either oncologist and/or nurses.

Rates of Smoking Cessation at 6 and 12 Months after a Clinical Tobacco Smoking Cessation Intervention in Head and Neck Cancer Patients in Northern Ontario, Canada

Smoking during cancer treatment is associated with reduced treatment response and cancer recurrence in patients with tobacco-related cancers. The purpose of this study was to examine smoking characteristics in head and neck cancer patients (n = 503) with a history of smoking and examine the impact of an intensive clinical tobacco intervention to patients who were currently smoking. All participants completed an interviewer-administered questionnaire at study enrollment which examined smoking behaviours, motivations to quit, and strategies used to cessate smoking. Follow-up assessments were completed at 6- and 12-months which monitored whether patients had quit smoking, remained cessated, or continued to smoke since study recruitment. For those who were currently smoking (n = 186, 37.0%), an intensive clinical tobacco intervention that utilized the 3A's-Ask, Advise, Arrange-and the Opt-Out approach was offered to assist with smoking cessation at their new patient visit and followed-up weekly during their head and neck radiation therapy for 7 weeks. At 6 months, 23.7% (n = 41) of those who were smoking successfully quit; 51.2% quit 'cold turkey' (defined as using no smoking cessation assistance, aids or pharmacotherapy to quit), while 34.9% used pharmacotherapy (varenicline (Champix)) to quit. On average, it took those who were smoking 1-5 attempts to quit, but once they quit they remained cessated for the duration of the study. Although the head and neck cancer patients in this study reported high levels of nicotine dependence, many were able to successfully cessate.

Risk factors associated with patient-reported fatigue among long-term oropharyngeal carcinoma survivors

BACKGROUND

The study objective is to identify risk factors associated with fatigue among long-term OPC survivors.

METHODS

This cross-sectional study included disease-free OPC survivors treated curatively between 2000 and 2013 who were surveyed from September 2015 to July 2016. The outcome variable was patient-reported fatigue. Multivariable logistic regression was used to identify factors associated with moderate to severe fatigue.

RESULTS

Among 863 OPC survivors, 17.4% reported moderate to severe fatigue. Self-reported thyroid problems (OR: 2.01; p = 0.003), current cigarette smoking at time of survey (OR: 3.85; p = 0.001), late lower cranial neuropathy (OR: 3.44; p = 0.002), and female sex (OR: 1.91; p = 0.010) were concurrent risk factors of reporting moderate to severe fatigue. Ipsilateral intensity-modulated radiotherapy (OR: 0.18; p = 0.014) was associated with lower risk of reporting moderate to severe fatigue.

CONCLUSIONS

Our study identified thyroid problems, smoking, and late lower cranial neuropathy as associated with moderate to severe fatigue. These findings should be further validated in prospective studies to address fatigue among OPC survivors.

A Comprehensive Program to Reduce Tobacco-related Cancers Through Actions by a National Cancer Institute-designated Cancer Center

Tobacco use accounts for 30% of all cancer-related deaths worldwide and 20% in the US, despite effective, evidence-based interventions for reducing tobacco use and tobacco-related cancers and deaths. In 2012, to reduce the burden of tobacco-related cancer and associated population-level risks across Texas, The University of Texas MD Anderson Cancer Center initiated the EndTobacco® program to promote statewide cancer control activities. We created evidence-based initiatives, established selection criteria, and implemented actions involving policy, education, and tobacco treatment services. As a result, EndTobacco has supported, educated, and convened local and state coalitions in policymaking; provided tobacco treatment education to health professionals; implemented Texas’ only certified tobacco treatment training program; and led an initiative to enhance the tobacco-free culture of the state’s publicly funded university system. Supported by commitments from MD Anderson, we developed and implemented evidence-based actions for tobacco control tailored to the center’s mission, values, expertise, resources, and partnerships. By 2021, the adult smoking rate in Texas dropped from 19.2% (2014) to 13.2%. Contributors to this drop include state tobacco control policies, programs and services from multiple agencies and associations, and EndTobacco activities that complement the statewide effort to prevent youth smoking initiation and increase quit attempts among youth and adults.

National assessment of recommendations from healthcare providers for smoking cessation among adults with cancer

Cancer survivors benefit from evidence-based smoking cessation treatment. A crucial first step in this process is a clinician recommending that the patient quit smoking. However, contemporary delivery of advice to quit among patients with cancer is not well known. In a cross-sectional analysis of all adult smokers included in a prospective population-representative study of US adults, we analyzed the frequency that patients reported receiving advice to quit smoking from a healthcare professional according to reported cancer history (no cancer, tobacco-related cancer, non-tobacco related cancer history). Among an estimated 28.3 million smokers, 9.3% reported a history of cancer, 48.8% of which were tobacco-related cancers. In general, advice to quit was reported by more (67.8%) cancer survivors than those adults without any cancer (56.0%). After adjustment for sociodemographic factors, smokers with a non tobacco-related cancer (0.51, 95% CI 0.32-0.83) and those without any cancer history (0.43, 95% CI 0.30-0.63) were both less likely to report being advised to quit smoking than patients with a tobacco-related cancer history.

Motivation to smoking cessation in head and neck cancer and dysplasia patients in confrontation with the attitudes of otorhinolaryngologists in delivering anti-smoking therapies

Objectives

The aim of the study was to determine the influence of oral, oropharyngeal, laryngeal and hypopharyngeal dysplasia and cancer diagnosis on motivation to smoking cessation in patients. Consecutively, we assessed the competence of ENT specialists in counseling anti-smoking therapies.

Methods

Questionnaire of expected support, Schneider motivation test and Fagerström Test for Nicotine Dependence (FTND) were administered to 50 smoking patients. The online survey was collected from 152 ENT doctors.

Results

Mean FTND score was 4.58 and Heaviness of Smoking Index (HSI) was 3.1. Patients with oral cavity and oropharyngeal cancer showed the greatest dependence to nicotine 7.67 and 5.25, respectively, and with hypopharyngeal cancer had the lowest 3.5, (p = 0.039). The ranges of HSI were significantly higher for younger patients (p = 0.036). 35 patients were adequately motivated to quit smoking, and their mean age was statistically higher (p = 0.05). Self-reported motivation to smoking cessation was 76%. Of 152 surveyed doctors, only 39% declared knowledge of the diagnostic and therapeutic cessation interventions. 75% showed interest in the training programs.

Time to put it out - nurse-facilitated tobacco treatment in a comprehensive cancer center

Few cancer patients receive guideline-concordant care for treatment of tobacco dependence. The purpose of this pilot trial was to obtain preliminary estimates of effectiveness of an evidence-based practice intervention on the delivery of tobacco treatment and cessation outcomes in cancer patients. We conducted a pragmatic implementation trial with a before-after design in 119 current or recently quit adult smokers with cancer who met with a clinician at a single National Cancer Institute designated comprehensive cancer center (CCC) (n = 61 pre-implementation, n = 58 post-implementation). We used a multi-component strategy based on the Chronic Care Model to implement National Comprehensive Cancer Network (NCCN) guidelines for smoking cessation. Smoking cessation counseling during the index visit was assessed by exit interview and patients were interviewed by phone to assess cessation outcomes at 3-month follow-up. Performance of cessation counseling and 7-day point prevalence abstinence (PPA) were compared across the pre- and post-implementation periods using log-logistic regression, accounting for clustering by nursing staff. More patients had received assistance in quitting at the index visit during the post-implementation period compared to the pre-implementation period (30 vs. 10%, p < .01). At 3-month follow-up, 38 and 14% of participants had discussed smoking cessation medication with a CCC healthcare professional and 57 and 27% of participants had used pharmacotherapy, respectively (p < .01 for both comparisons). Seven-day PPA at 3-month follow-up was similar in both periods, however (14 vs. 12%, respectively). A multi-component tobacco treatment intervention increased the proportion of smokers who received assistance in quitting smoking during usual cancer care but did not improve cessation outcomes.

Associations between cancer diagnosis and patients' responses to an inpatient tobacco treatment intervention

BACKGROUND

Diagnosis of a chronic illness, such as cancer may influence health behavior changes, such as smoking cessation. The present analyses examine associations between a cancer diagnosis (i.e., yes or no) and response to an opt-out smoking cessation bedside intervention provided to hospitalized patients. It was hypothesized that patients with a past or present cancer diagnosis would report higher motivation and engagement with quitting smoking, and higher rates of smoking abstinence after hospital discharge, compared to those without a cancer diagnosis.

METHODS

Chart review was conducted on 5287 inpatients who accepted bedside treatment from a counselor and opted-in to automated follow-up calls from July 2014 to December 2019.

RESULTS

At the time of inpatient assessment, those with a past or present cancer diagnosis (n = 419, 7.9%) endorsed significantly higher levels of importance of quitting than those without a cancer diagnosis (3.92/5 vs. 3.77/5), and were more likely to receive smoking cessation medication upon discharge (17.9% vs. 13.3%). Follow-up data from 30-days post-discharge showed those with a cancer diagnosis endorsed higher rates of self-reported abstinence (20.5%) than those without a cancer diagnosis (10.3%; p < 0.001).

CONCLUSION

Being hospitalized for any reason provides an opportunity for smokers to consider quitting. Having a previous diagnosis of cancer appears to increase intention to quit and lead to higher rates of smoking cessation in patients who are hospitalized compared to patients without cancer. Future research needs to work toward optimizing motivation for smoking cessation while admitted to a hospital and on improving quit rates for all admitted patients, regardless of diagnosis.

It Takes Two to Tango: Patients' and Providers' Perspectives in Tobacco Cessation and Head/Neck Cancer

BACKGROUND

Tobacco cessation among patients with head/neck cancer continues to be challenging despite evidence that cessation improves treatment outcomes. The purpose of this study was to understand barriers/facilitators to tobacco cessation among patients with head/neck cancer and health care providers and to obtain perspectives toward the development of a patient-centered tobacco cessation intervention.

MATERIALS AND METHODS

In-depth qualitative interviews with 10 health care providers and 21 patients with head/neck cancer (12 inpatients and 9 outpatients) who were current or former smokers.

RESULTS

Health was a common motivator to quit among patients. Although most patients indicated that their health care provider asked and advised them to quit, they were unaware of cessation resources. Suggestions for a tobacco cessation program included involvement of former smokers, health care provider involvement/counseling, supporting written materials, and incorporating follow-up and family support. Health care providers identified patients' anger/frustration associated with the disease, social/demographic issues, and poor quality of life as the three most frequent challenges in treating patients. Although all providers reported asking about tobacco use, 70% emphasized a lack of formal training in tobacco cessation and lack of time. Their suggestions for a cessation program included having a "quarterback" responsible for this component with support from the entire health care team and continuity between outpatient and inpatient services to promote cessation, prevent relapse, and highlight the importance of follow-up and social support.

CONCLUSION

There is great interest and need, both from patients and providers, for tobacco cessation services in the oncology setting tailored for patients with head/neck cancer in the context of cancer care.

IMPLICATIONS FOR PRACTICE

Although the combination of pharmacotherapy and cognitive-behavioral intervention is the standard evidence-based treatment for tobacco dependence, it must be adapted to meet the needs and wants of patients and providers to be effective. This study provides an in-depth examination of such needs among patients with head and neck cancer and providers in the context of cancer care. Providers and patients emphasized the need of having a trained health care provider dedicated to providing tobacco cessation through seamless integration between outpatient and inpatient services as well as follow-up with an emphasis on family involvement throughout the process.

Impact of deep learning-determined smoking status on mortality of cancer patients: never too late to quit

Background

Persistent smoking after cancer diagnosis is associated with increased overall mortality (OM) and cancer mortality (CM). According to the 2020 Surgeon General's report, smoking cessation may reduce CM but supporting evidence is not wide. Use of deep learning-based modeling that enables universal natural language processing of medical narratives to acquire population-based real-life smoking data may help overcome the challenge. We assessed the effect of smoking status and within-1-year smoking cessation on CM by an in-house adapted freely available language processing algorithm.

Materials and methods

This cross-sectional real-world study included 29 823 patients diagnosed with cancer in 2009-2018 in Southwest Finland. The medical narrative, International Classification of Diseases-10th edition codes, histology, cancer treatment records, and death certificates were combined. Over 162 000 sentences describing tobacco smoking behavior were analyzed with ULMFiT and BERT algorithms.

Results

The language model classified the smoking status of 23 031 patients. Recent quitters had reduced CM [hazard ratio (HR) 0.80 (0.74-0.87)] and OM [HR 0.78 (0.72-0.84)] compared to persistent smokers. Compared to never smokers, persistent smokers had increased CM in head and neck, gastro-esophageal, pancreatic, lung, prostate, and breast cancer and Hodgkin's lymphoma, irrespective of age, comorbidities, performance status, or presence of metastatic disease. Increased CM was also observed in smokers with colorectal cancer, men with melanoma or bladder cancer, and lymphoid and myeloid leukemia, but no longer independently of the abovementioned covariates. Specificity and sensitivity were 96%/96%, 98%/68%, and 88%/99% for never, former, and current smokers, respectively, being essentially the same with both models.

Conclusions

Deep learning can be used to classify large amounts of smoking data from the medical narrative with good accuracy. The results highlight the detrimental effects of persistent smoking in oncologic patients and emphasize that smoking cessation should always be an essential element of patient counseling.

•

Deep learning/universal language modeling was used to extract smoking status of cancer patients. Good accuracy was observed.

•

Those who continue smoking after cancer diagnosis had increased CM compared to never smokers.

•

Recent within-1-year cessation reduced this mortality.

•

Detrimental effects of smoking were observed in multiple types of early- and advanced-stage cancers, including the elderly.

•

We conclude that smoking cessation support should always be included in cancer care.

Engagement and Effectiveness of a Smoking Cessation Quitline Intervention in a Thoracic Surgery Clinic

Importance

Smoking quitline programs effectively promote smoking cessation in outpatient primary care settings.

Objective

To examine the factors associated with smoking quitline engagement and smoking cessation among patients undergoing thoracic surgery who consented to a quitline electronic referral.

Design, Setting, and Participants

A retrospective cohort study was conducted from January 1, 2014, to December 31, 2018, among 111 active smoking patients referred to the quitline from a thoracic surgery outpatient clinic visit. Patients were divided into operative and nonoperative cohorts.

Main Outcomes and Measures

Primary outcomes were engagement rates in the quitline program and successful smoking cessation. Secondary outcomes were self-reported point prevalence abstinence at 1 month and 6 months after the smoking quit date.

Results

Of 111 patients (62 men; mean [SD] age, 61.8 [11.2] years) who had a quitline referral, 58 (52%) underwent surgery, and 32 of these 58 patients (55%) participated in the program. Of the 53 nonoperative patients (48%), 24 (45%) participated in the program. In the operative cohort, there was no difference in the smoking cessation rate between quitline participants and nonparticipants (21 of 32 [66%] vs 16 of 6 [62%]; P = .79) or in point prevalence abstinence at 1 month (23 of 32 [72%] vs 14 of 25 [56%]; P = .27) or 6 months (14 of 28 [50%] vs 6 of 18 [33%]; P = .36). Similarly, in the nonoperative cohort, there was no difference in the smoking cessation rate between quitline participants and nonparticipants (8 of 24 [33%] vs 11 of 29 [38%]; P = .78) or in point prevalence abstinence at 1 month (7 of 24 [29%] vs 8 of 27 [30%]; P = .99) or 6 months (6 of 23 [26%] vs 6 of 25 [24%]; P = .99). Regardless of quitline participation, operative patients had a 1.8-fold higher proportion of successful smoking cessation compared with nonoperative patients (37 of 58 [64%] vs 19 of 53 [36%]; P = .004) as well as a 2.2-fold higher proportion of 1-month point prevalence abstinence (37 of 57 [65%] vs 15 of 51 [29%]; P < .001) and a 1.8-fold higher proportion of 6-month point prevalence abstinence (20 of 45 [44%] vs 12 of 48 [25%]; P = .05). Having surgery doubled the odds of smoking cessation (odds ratio, 2.44; 95% CI, 1.06-5.64; P = .04) and quitline engagement tripled the odds of remaining smoke free at 6 months (odds ratio, 3.57; 95% CI, 1.03-12.38; P = .04).

Conclusions and Relevance

Patients undergoing thoracic surgery were nearly twice as likely to quit smoking as those who did not have an operation, and smoking quitline participation further augmented point prevalence abstinence. Improved smoking cessation rates, even among nonoperative patients, were associated with appropriate outpatient counseling and intervention.

Time-varying survival effects for squamous cell carcinomas at oropharyngeal and nonoropharyngeal head and neck sites in the United States, 1973-2015

BACKGROUND

Anatomical site is strongly associated with head and neck cancer etiology, and etiology and patient sociodemographic characteristics are prognostic factors for survival. It is not known whether the effects of these predictors persist over the postdiagnosis period or are strongest proximal to the time of diagnosis.

METHODS

Using survival times and causes of death for 180,434 patients with head and neck cancer in the Surveillance, Epidemiology, and End Results cancer registry (1973-2015), the empirical cumulative incidences of cancer-specific death and other-cause death were calculated with a competing risks framework, and the time-dependent effects (hazard ratios) of anatomical tumor site (oropharynx, oral cavity, or hypopharynx/larynx), age, sex, race, and year of diagnosis on cancer-specific death and other-cause death, stratified by tumor stage, were estimated.

RESULTS

All effects were significantly time-varying (P < .001). Patients with nonoropharyngeal cancer had a higher hazard of cancer-specific death but a similar cumulative fraction of deaths because of a higher rate of death from other causes. Cancer-specific survival has not changed for patients with nonoropharyngeal cancer over the past decades but has improved since 2000 for patients with oropharyngeal cancer. The effects of age and sex on cancer survival were strongest proximal to the diagnosis, whereas the effect of race persisted over time.

CONCLUSIONS

Recent improvements in survival for patients with oropharyngeal cancer may be due more to an increasing fraction of cancers attributable to human papillomavirus than to increasing treatment effectiveness. The prognostic strength of anatomical site and other predictors changes over the postdiagnosis period.

LAY SUMMARY

It is generally assumed that the effects of tumor and personal characteristics on the survival of patients with head and neck cancer are fixed over time, but this study shows that many factors are most important only in the first few years after diagnosis. Also, recent improvements in the survival of patients with head and neck cancer appear to benefit only patients with cancers of the oropharynx. The improvements may be due more to an increasing fraction of cancers caused by human papillomavirus (which generally have better outcomes) than to advances in head and neck cancer treatment overall.

Preventing smoking relapse in patients with cancer: A randomized controlled trial

BACKGROUND

Abstaining from smoking after a cancer diagnosis is critical to mitigating the risk of multiple adverse health outcomes. Although many patients with cancer attempt to quit smoking, the majority relapse. The current randomized controlled trial evaluated the efficacy of adapting an evidence-based smoking relapse prevention (SRP) intervention for patients with cancer.

METHODS

The trial enrolled 412 patients newly diagnosed with cancer who had recently quit smoking. Participants were randomized to usual care (UC) or SRP. Participants in the UC group received the institution's standard of care for treating tobacco use. Participants in the SRP group in addition received a targeted educational DVD plus a validated self-help intervention for preventing smoking relapse. The primary outcome was smoking abstinence at 2 months, 6 months, and 12 months.

RESULTS

Abstinence rates for participants in the SRP and UC groups were 75% versus 71% at 2 months and 69% versus 64% at 6 months (Ps > .20). At 12 months, abstinence rates among survivors were 68% for those in the SRP group and 63% for those in the UC group (P = .38). Post hoc analyses revealed that across 2 months and 6 months, patients who were married/partnered were more likely to be abstinent after SRP than UC (P = .03).

CONCLUSIONS

A smoking relapse prevention intervention did not reduce relapse rates overall, but did appear to have benefited those participants who had the social support of a partner. Future work is needed to extend this effect to the larger population of patients.

Impact of a tobacco treatment program on abstinence and survival rates among current smokers with head and neck squamous cell carcinoma

BACKGROUND

Approximately one quarter of head and neck cancer (HNC) patients smoke cigarettes at the time of diagnosis. Despite HNC guideline recommendations to treat tobacco dependence, the effectiveness of treatment in this population is poorly described.

METHODS

This retrospective cohort review evaluated 117 current smokers with p16-negative mucosal head and neck squamous cell carcinoma prospectively enrolled in a tobacco treatment program. Seven-day point prevalence tobacco abstinence rates at 9 months and survival outcomes were compared among abstinent and nonabstinent groups.

RESULTS

Median follow-up among survivors was 62.4 months. Forty percent of patients were abstinent at 9 months according to intention-to-treat analysis. After adjustment for age, comorbidity and site, abstinent stage I to II patients had a decreased risk of death compared to smoking stage I to II patients (HR 0.15, 95% CI 0.03-0.82).

CONCLUSIONS

High cohort abstinence rates and favorable survival among abstinent patients with early-stage HNC confirm the importance of tobacco dependence treatment in this population.

European practice patterns and barriers to smoking cessation after a cancer diagnosis in the setting of curative versus palliative cancer treatment

BACKGROUND

Smoking cessation after a cancer diagnosis is associated with improved overall survival. Few studies have reported oncologists' cessation practice patterns, but differences between the curative and palliative settings have not been described. We aimed to study the oncologist's perceptions on patients' tobacco use, current practices and barriers to providing smoking cessation support, while distinguishing between treatment with curative (C) and palliative (P) intent.

METHODS

In 2019, an online 34-item survey was sent to approximately 6235 oncologists from 16 European countries. Responses were descriptively reported and compared by treatment setting.

RESULTS

Responses from 544 oncologists were included. Oncologists appeared to favour addressing tobacco in the curative setting more than in the palliative setting. Oncologists believe that continued smoking impacts treatment outcomes (C: 94%, P: 74%) and that cessation support should be standard cancer care (C: 95%, P: 63%). Most routinely assess tobacco use (C: 93%, P: 78%) and advise patients to stop using tobacco (C: 88%, P: 54%), but only 24% (P)-39% (C) routinely discuss medication options, and only 18% (P)-31% (C) provide cessation support. Hesitation to remove a pleasurable habit (C: 13%, P: 43%) and disbelieve on smoking affecting outcomes (C: 3%, P: 14%) were disparate barriers between the curative and palliative settings (p < 0.001), but dominant barriers of time, resources, education and patient resistance were similar between settings.

CONCLUSION

Oncologists appear to favour addressing tobacco use more in the curative setting; however, they discuss medication options and/or provide cessation support in a minority of cases. All patients who report current smoking should have access to evidence-based smoking cessation support, also patients treated with palliative intent given their increasing survival.

Strategies for Referring Cancer Patients in a Smoking Cessation Program

Most people who smoke and develop cancer are unable to quit smoking. To address this, many cancer centers have now opened smoking cessation programs specifically designed to help cancer patients to quit. An important question has now emerged—what is the most effective approach for engaging smokers within a cancer center in these smoking cessation programs? We report outcomes from a retrospective observational study comparing three referral methods—traditional referral, best practice advisory (BPA), and direct outreach—on utilization of the Duke Cancer Center Smoking Cessation Program. We found that program utilization rate was higher for direct outreach (5.4%) than traditional referral (0.8%), p < 0.001, and BPA (0.2%); p < 0.001. Program utilization was 6.4% for all methods combined. Inferring a causal relationship between referral method and program utilization was not possible because the study did not use a randomized design. Innovation is needed to generate higher utilization rates for cancer center smoking cessation programs.

Assessment of Trends in Cigarette Smoking Cessation After Cancer Diagnosis Among US Adults, 2000 to 2017

IMPORTANCE

Continued cigarette smoking after cancer diagnosis has been shown to adversely alter the cancer survivor's health outcomes and quality of life. Although considerable progress has been made in reducing cigarette smoking in the United States over the last decades, trends in cigarette smoking cessation among cancer survivors have not yet been fully investigated.

OBJECTIVE

To evaluate temporal trends in cigarette smoking cessation and their sociodemographic and behavioral correlates in the US population of adult cancer survivors.

DESIGN, SETTING, AND PARTICIPANTS

This investigation was a serial cross-sectional study of the National Health Interview Survey (NHIS) from 2006 to 2018, a household survey of civilian US residents who were 18 years or older. Data analysis was performed from June to October 2019. The NHIS is population based and representative of the US population. Included in this study were 381 989 respondents to the NHIS in 2006 to 2018.

MAIN OUTCOMES AND MEASURES

The primary outcome was the probability of quitting cigarette smoking after first cancer diagnosis. Secondary outcomes were factors associated with quitting cigarette smoking after cancer diagnosis.

RESULTS

Data on 381 989 adults (weighted N = 239 114 051; mean [SD] age, 48.96 [18.28] years; 211 508 [55.37%] female; 61.90% non-Hispanic White, 13.97% non-Hispanic Black, and 16.22% Hispanic individuals) 18 years or older were analyzed from the 2006 to 2018 NHIS, of whom 8.80% (n = 35 524; weighted n = 21 016 720) were diagnosed with cancer. Among cancer survivors diagnosed between 2000 and 2017, the age-adjusted prevalence of current cigarette smoking at the time of first cancer diagnosis was 24.45% (n = 4054; weighted n = 2 395 173). The probability of reporting a cigarette smoking cessation event after first cancer diagnosis statistically significantly increased with each year of cancer diagnosis (hazard ratio [HR], 1.05; 95% CI, 1.02-1.08), indicating upward trends in the prevalence of quitting cigarette smoking over time. Older individuals (HR, 1.02; 95% CI, 1.01-1.03), individuals diagnosed as having a smoking-related cancer (HR, 1.28; 95% CI, 1.06-1.54), individuals with an undergraduate degree (HR, 1.39; 95% CI, 1.08-1.79) or a postgraduate degree (HR, 1.61; 95% CI, 1.18-2.20), and individuals with obesity (HR, 1.32; 95% CI, 1.06-1.63) had a higher probability of reporting a cigarette smoking cessation event after cancer diagnosis, whereas individuals living below the poverty level (HR, 0.62; 95% CI, 0.48-0.81) had a lower probability of reporting a cigarette smoking cessation event after cancer diagnosis.

CONCLUSIONS AND RELEVANCE

In this nationally representative survey of the US adult population, the likelihood of cigarette smoking cessation among cancer survivors increased with the year of cancer diagnosis from 2000 to 2017; however, the improvement is incremental, and the prevalence of smoking remained high among this population. Considering the projected increase in the population of cancer survivors in the United States, urgent action is needed to increase cigarette smoking cessation rates in this high-risk population.

Rapid Scaling Up of Telehealth Treatment for Tobacco-Dependent Cancer Patients During the COVID-19 Outbreak in New York City

Background: The (COVID-19) pandemic resulted in sudden disruption of routine clinical care necessitating rapid transformation to maintain clinical care while safely reducing virus contagion. Introduction: Memorial Sloan Kettering (MSK) experienced a rapid evolution from delivery of in-person cessation counseling services to virtual telehealth treatments for our tobacco-dependent cancer patients. Aim: To examine the effect of rapid scaling of tobacco treatment telehealth on patient engagement, as measured by attendance rates for in-person counseling visits versus remote telehealth counseling visits. We also describe the patient, clinician, and health care system challenges encountered in rapid expansion of individual and group tobacco telehealth services. Methods: Data collected from the electronic medical record during the first 4 months of the COVID-19 pandemic were examined for tobacco treatment counseling. Results: From January 1, 2020 to March 30, 2020, markedly improved patient engagement was observed in ambulatory tobacco treatment services with greater attendance at scheduled telehealth visits than in-person visits, 75% versus 60.3%, odds ratio 1.84 (confidence interval: 1.26-2.71; p < 0.001). In addition, bedside hospital counseling visits were transformed into inpatient telephone visits with high levels of sustained patient engagement. Lastly, group telehealth services were launched rapidly to increase capacity and provide greater psychosocial support for cancer patients struggling with tobacco dependence. Discussion: Clinical, Information Technology (IT), and hospital system barriers were successfully addressed for most cancer patients seeking individual telehealth treatment. Group telehealth services were found to be feasible and acceptable. Conclusions: MSK's rapid leap into virtual care delivery mitigated disruption of tobacco treatment services and demonstrated strong feasibility and acceptance for managing complex tobacco-dependent patients.

Smoking Behaviors in Survivors of Smoking-Related and Non-Smoking-Related Cancers

IMPORTANCE

The population of cancer survivors is rapidly growing in the US. Tobacco smoking is associated with many cancers; however, whether cigarette smoking behaviors among cancer survivors vary according to cancer type-that is, smoking-related cancers (SRCs) vs non-smoking-related cancers (NSRCs)-remains unclear.

OBJECTIVES

To examine cigarette smoking prevalence and behaviors (ie, continuing or quitting smoking) among cancer survivors and to compare them between survivors of SRCs and NSRCs.

DESIGN, SETTING, AND PARTICIPANTS

This study was a cross-sectional analysis of the 2017 National Health Interview Survey, a household survey of civilian US residents who were aged 18 years or older. The National Health Interview Survey is population based and is representative of the US population. Data analysis was performed from June to October 2019.

MAIN OUTCOMES AND MEASURES

The primary outcomes were prevalence of current cigarette smoking among cancer survivors and prevalence of continuing smoking and quitting smoking after a cancer diagnosis. Secondary outcomes included factors associated with continued smoking vs quitting smoking after a cancer diagnosis.

RESULTS

A total of 26 742 respondents (mean [SD] age, 50.97 [18.61] years; 14 646 women [51.76%]) to the 2017 National Health Interview Survey were included in this study. Of the 3068 individuals (9.42%) in the study population who had cancer, 589 (19.96%) were SRC survivors, 2297 (74.50%) were NSRC survivors, 168 (4.96%) were survivors of both SRC and NSRC, and the remaining 14 (0.58%) had missing information about the type of cancer. Four hundred forty-nine SRC survivors (54.08%) were women, compared with 1412 NSRC survivors (54.30%). Ninety-six SRC survivors (15.69%) and 151 NSRC survivors (7.99%) were younger than 45 years. Overall, 372 cancer survivors (13.16%) were current smokers. Current smoking prevalence was higher among survivors of SRCs (145 survivors [19.78%]) compared with NSRC survivors (251 survivors [10.63%]). Among cancer survivors, 309 current smokers at cancer diagnosis (43.96%) reported having successfully quit smoking and 372 (56.04%) reported continuing smoking. Among the continuing smokers, 176 (56.49%) reported an unsuccessful quit attempt in the last 12 months. After cancer diagnosis, SRC survivors had higher odds of continued smoking compared with NSRC survivors (odds ratio [OR], 2.10; 95% CI, 1.12-3.93; P = .02). Men (OR, 1.93; 95% CI, 1.05-3.57; P = .04), those with angina pectoris (OR, 5.40; 95% CI, 1.33-21.91; P = .02), and those with chronic bronchitis (OR, 2.55; 95% CI, 1.05-6.19; P = .04) had higher odds of continued smoking, whereas Hispanic participants (compared with non-Hispanic white participants: OR, 0.18; 95% CI, 0.05-0.68; P = .01) and married participants (compared with never married participants: OR, 0.33; 95% CI, 0.12-0.96; P = .04) had lower odds of continued smoking.

CONCLUSIONS AND RELEVANCE

These findings suggest that compared with NSRC survivors, SRC survivors may be at higher risk of being cigarette smokers at cancer diagnosis and of continuing smoking afterward. Although smoking cessation interventions are critically important for all cancer survivors, special efforts should target survivors of SRCs.

Design and Pilot Implementation of an Electronic Health Record-Based System to Automatically Refer Cancer Patients to Tobacco Use Treatment

Continued tobacco use after cancer diagnosis is detrimental to treatment and survivorship. The current reach of evidence-based tobacco treatments in cancer patients is low. As a part of the National Cancer Institute Cancer Center Cessation Initiative, the Mayo Clinic Cancer Center designed an electronic health record (EHR, Epic^©)-based process to automatically refer ambulatory oncology patients to tobacco use treatment, regardless of intent to cease tobacco use(“opt out”). The referral and patient scheduling, accomplished through a best practice advisory (BPA) directed to staff who room patients, does not require a co-signature from clinicians. This process was piloted for a six-week period starting in July of 2019 at the Division of Medical Oncology, Mayo Clinic, Rochester, MN. All oncology patients who were tobacco users were referred for tobacco treatment by the rooming staff (n = 210). Of these, 150 (71%) had a tobacco treatment appointment scheduled, and 25 (17%) completed their appointment. We conclude that an EHR-based “opt-out” approach to refer patients to tobacco dependence treatment that does not require active involvement by clinicians is feasible within the oncology clinical practice. Further work is needed to increase the proportion of scheduled patients who attend their appointments.

Tobacco Dependence Treatment in Oncology: Initial Patient Clinical Characteristics and Outcomes from Roswell Park Comprehensive Cancer Center

Despite the importance of smoking cessation to cancer care treatment, historically, few cancer centers have provided treatment for tobacco dependence. To address this gap, the National Cancer Institute (NCI) launched the Cancer Center Cessation Initiative (C3i). As part of this effort, this study examined implementation outcomes in a cohort of cancer survivors (CSs) who smoked cigarettes in the first year of an ongoing process to develop and implement a robust Tobacco Treatment Service at Roswell Park Comprehensive Cancer Center. We provide a comprehensive description of the new tobacco use assessment and referral process, and of the characteristics of cancer survivors who agreed to treatment including traditional tobacco-related psychosocial and cancer treatment-related characteristics and novel characteristics such as delay discounting rates. We also examine characteristic differences among those who agreed to treatment between those who attended and those who did not attend treatment. As the new tobacco assessment was implemented, the number of referrals increased dramatically. The mean number of treatment sessions attended was 4.45 (SD = 2.98) and the six-month point prevalence intention to treat abstinence rate among those who attended was 22.7%. However, only 6.4% agreed to treatment and 4% attended at least one treatment session. A large proportion of cancer survivors who agreed to treatment were women, of older age, of lower socioeconomic status (SES), and who had high levels of depressive symptomology. The findings demonstrate that the implementation of system changes can significantly improve the identification of cancer survivors who use tobacco and are referred to tobacco use treatment. Among those who attend, treatment is effective. However, the findings also suggest that a systematic assessment of barriers to engagement is needed and that cancer survivors may benefit from additional treatment tailoring. We present plans to address these implementation challenges. Systematic electronic medical record (EMR)-sourced referral to tobacco treatment is a powerful tool for reaching cancer survivors who smoke, but more research is needed to determine how to enhance engagement and tailor treatment processes.

The Emergence of a Sustainable Tobacco Treatment Program across the Cancer Care Continuum: A Systems Approach for Implementation at the University of California Davis Comprehensive Cancer Center

Tobacco treatment is increasingly recognized as important to cancer care, but few cancer centers have implemented sustainable tobacco treatment programs. The University of California Davis Comprehensive Cancer Center (UCD CCC) was funded to integrate tobacco treatment into cancer care. Lessons learned from the UCD CCC are illustrated across a systems framework with the Cancer Care Continuum and by applying constructs from the Consolidated Framework for Implementation Research. Findings demonstrate different motivational drivers for the cancer center and the broader health system. Implementation readiness across the domains of the Cancer Care Continuum with clinical entities was more mature in the Prevention domain, but Screening, Diagnosis, Treatment, and Survivorship domains demonstrated less implementation readiness despite leadership engagement. Over a two-year implementation process, the UCD CCC focused on enhancing information and knowledge sharing within the treatment domain with the support of the cancer committee infrastructure, while identifying available resources and adapting workflows for various cancer care service lines. The UCD CCC findings, while it may not be generalizable to all cancer centers, demonstrate the application of conceptual frameworks to accelerate implementation for a sustainable tobacco treatment program. Key common elements that may be shared across oncology settings include a state quitline for an adaptable intervention, cancer committees for outer/inner setting infrastructure, tobacco quality metrics for data reporting, and non-physician staff for integrated services.

An Implementation Trial to Improve Tobacco Treatment for Cancer Patients: Patient Preferences, Treatment Acceptability and Effectiveness

Continued smoking after a cancer diagnosis increases mortality, risk of recurrence, and negatively impacts treatment effectiveness. However, utilization of tobacco use cessation treatment among cancer patients remains low. We conducted a clinical trial assessing patient preferences, treatment acceptability, and preliminary effectiveness (7-day point prevalence at 12 weeks) of three tobacco treatment options among cancer patients at an academic health center. Implementation strategies included electronic referral and offering the choice of three treatment options: referral to external services, including the quitline (PhoneQuit) and in-person group counseling (GroupQuit), or an internal service consisting of 6-week cognitive behavioral therapy delivered via smartphone video conferencing by a tobacco treatment specialist (SmartQuit). Of 545 eligible patients, 90 (16.5%) agreed to enroll. Of the enrolled patients, 39 (43.3%) chose PhoneQuit, 37 (41.1%) SmartQuit, and 14 (15.6%) GroupQuit. Of patients reached for 12-week follow-up (n = 35), 19 (54.3%) reported receiving tobacco treatment. Of all patients referred, 3 (7.7%) PhoneQuit, 2 (5.4%) SmartQuit, and 2 (14.3%) GroupQuit patients reported 7-day point prevalence abstinence from smoking at 12 weeks. Participants rated the SmartQuit intervention highly in terms of treatment acceptability. Results indicate that more intensive interventions may be needed for this population, and opportunities remain for improving reach and utilization.

Using a Family Systems Approach to Treat Tobacco Use among Cancer Patients

Tobacco use treatment is an essential component of cancer care. Family members play a significant role in smoking behavior, but more research is needed regarding the development, implementation, and impact of family-based interventions in cancer care. The UNC Tobacco Treatment Program conducted an 18-month pilot study to examine the feasibility of implementing a family systems approach to treat tobacco use among patients at the North Carolina Cancer Hospital and to measure the impact of such an approach on patient abstinence. Implementation included four phases: (1) modifying the electronic health record and monthly report generated from the electronic health record; (2) training Tobacco Treatment Specialists to provide family counseling; (3) integrating family members into patients' treatment; and (4) conducting six-month follow-up calls. During the course of the study, 42% (N = 221/532) of patients had family members integrated into their tobacco use treatment. Only 21 patients (4%) had family members present but not integrated into the treatment plan. At the six-month follow up time point, the seven-day point-prevalence quit rate for patients with family integration was 28% (N = 56/200), compared to 23% (N = 67/291) (p = 0.105) for patients without family integration. Integration of family members is clearly possible in an academic medical center's oncology tobacco treatment program. Although pilot results were not statistically significant at 6 months, a potentially higher quit rate suggests a need for expanded research on methods to integrate family members in oncology settings for patients with tobacco-related cancers.