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Tsui J, Sloan K, Sheth R, Ewusi Boisvert E, Nieva J, Kim AW, Pang RD, Sussman S, Kirkpatrick M. Implementation planning for equitable tobacco treatment services: a mixed methods assessment of contextual facilitators and barriers in a large comprehensive cancer center. Transl Behav Med 2023; 13:539-550. [PMID: 36940412 PMCID: PMC10848232 DOI: 10.1093/tbm/ibac122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
Abstract
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.
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Affiliation(s)
- Jennifer Tsui
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Kylie Sloan
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rajiv Sheth
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Jorge Nieva
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
- Department of Medicine, Division of Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anthony W Kim
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Raina D Pang
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
- Department of Psychology, University of Southern California, Los Angeles, CA, USA
| | - Steve Sussman
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Matthew Kirkpatrick
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
- Department of Psychology, University of Southern California, Los Angeles, CA, USA
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Lee JJW, Kunaratnam V, Kim CJH, Pienkowski M, Hueniken K, Sahovaler A, Lam ACL, Davies JC, Brown CM, De Almeida JR, Huang SH, Waldron JN, Spreafico A, Hung RJ, Xu W, Goldstein DP, Liu G. Cigarette smoking cessation, duration of smoking abstinence, and head and neck squamous cell carcinoma prognosis. Cancer 2023; 129:867-877. [PMID: 36653915 DOI: 10.1002/cncr.34620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/20/2022] [Accepted: 11/07/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Tobacco use is a major risk factor for developing head and neck squamous cell carcinoma (HNSCC). However, the prognostic associations with smoking cessation are limited. The authors assessed whether smoking cessation and increased duration of abstinence were associated with improved overall (OS) and HNSCC-specific survival. METHODS Clinicodemographic and smoking data from patients with HNSCC at Princess Margaret Cancer Center (2006-2019) were prospectively collected. Multivariable Cox and Fine and Gray competing-risk models were used to assess the impact of smoking cessation and duration of abstinence on overall mortality and HNSCC-specific/noncancer mortality, respectively. RESULTS Among 2482 patients who had HNSCC, former smokers (adjusted hazard ratio [aHR], 0.71; 95% CI, 0.58-0.87; p = .001; N = 841) had a reduced risk of overall mortality compared with current smokers (N = 931). Compared with current smokers, former smokers who quit >10 years before diagnosis (long-term abstinence; n = 615) had the most improved OS (aHR, 0.72; 95% CI, 0.56-0.93; p = .001). The 5-year actuarial rates of HNSCC-specific and noncancer deaths were 16.8% and 9.4%, respectively. Former smokers (aHR, 0.71; 95% CI, 0.54-0.95; p = .019) had reduced HNSCC-specific mortality compared with current smokers, but there was no difference in noncancer mortality. Abstinence for >10 years was associated with decreased HNSCC-specific death compared with current smoking (aHR, 0.64; 95% CI, 0.46-0.91; p = .012). Smoking cessation with a longer duration of quitting was significantly associated with reduced overall and HNSCC-specific mortality in patients who received primary radiation. CONCLUSIONS Smoking cessation before the time of diagnosis reduced overall mortality and cancer-specific mortality among patients with HNSCC, but no difference was observed in noncancer mortality. Long-term abstinence (>10 pack-years) had a significant OS and HNSCC-specific survival benefit.
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Affiliation(s)
- John J W Lee
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Vijay Kunaratnam
- Department of Biostatistics, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Christina J H Kim
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Martha Pienkowski
- Department of Biostatistics, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Katrina Hueniken
- Department of Biostatistics, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Axel Sahovaler
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada.,Head and Neck Surgery, University College London Hospitals, London, UK
| | - Andrew C L Lam
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Joel C Davies
- Department of Otolaryngology-Head and Neck Surgery, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Catherine M Brown
- Department of Biostatistics, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - John R De Almeida
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Shao Hui Huang
- Department of Radiation Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - John N Waldron
- Department of Radiation Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Anna Spreafico
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Rayjean J Hung
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Geoffrey Liu
- Department of Biostatistics, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Cooper SL, Kovar V, Levinson AH. Developing a Collaborative, Team-Based Smoking Cessation Treatment Program in an Outpatient Oncology Setting. JCO Oncol Pract 2023; 19:e115-e124. [PMID: 36516366 PMCID: PMC10166398 DOI: 10.1200/op.22.00273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 10/19/2022] [Accepted: 10/26/2022] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Sara L. Cooper
- Department of Community and Behavioral Health, University of Colorado School of Public Health, Aurora, CO
| | - Vladka Kovar
- Department of Community and Behavioral Health, University of Colorado School of Public Health, Aurora, CO
| | - Arnold H. Levinson
- Department of Community and Behavioral Health, University of Colorado School of Public Health, Aurora, CO
- University of Colorado Cancer Center, Aurora, CO
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LeLaurin JH, Theis RP, Dallery J, Silver NL, Markham MJ, Staras SA, Xing C, Shenkman EA, Warren GW, Salloum RG. Implementation strategies for integrating tobacco cessation treatment in cancer care: A qualitative study. IMPLEMENTATION RESEARCH AND PRACTICE 2022; 3:26334895221112153. [PMID: 36909717 PMCID: PMC9924274 DOI: 10.1177/26334895221112153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose The objective of this study was to determine how to optimize implementation of tobacco cessation treatment interventions in cancer care by (1) investigating the feasibility and acceptability of a multi-level approach to tobacco cessation treatment intervention, (2) identifying barriers and facilitators to implementation, and (3) eliciting additional strategies to improve implementation of the intervention. Methods We conducted qualitative interviews with oncologists (n = 15) from one large academic health center in the Southeastern United States. We asked about their knowledge, attitudes, and current practices regarding tobacco use screening and treatment. We also asked about two proposed strategies to support implementation of tobacco cessation treatment: (1) developing a registry of tobacco users in collaboration with the state-run tobacco cessation program, and (2) providing on-site tobacco cessation counseling from trained professionals. Results Oncologists saw addressing tobacco use as valuable; however, they felt restricted from consistently addressing tobacco use by multi-level barriers such as workload, electronic health record (EHR) design, patient anxiety, and low self-efficacy for treating tobacco dependence. Oncologists responded positively to on-site treatment and felt this strategy would increase treatment accessibility and enhance engagement. Reaction to developing a registry of tobacco users was mixed, with concerns regarding lack of oncologist involvement and patient privacy expressed. Other suggested strategies for supporting implementation of tobacco cessation treatment included reducing referral complexity, establishing financial or quality incentives for oncologists, and leveraging existing EHR tools to facilitate integration of cessation interventions into clinic workflows. Conclusion We identified several challenges to implementing tobacco use treatment in cancer care; however, we considered strategies to overcome these barriers that were viewed as feasible and acceptable. Our work highlights the importance of engaging stakeholders in implementation efforts. Future work should explore the impact of the implementation strategies identified in this study.
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Affiliation(s)
- Jennifer H LeLaurin
- Department of Health Outcomes and Biomedical Informatics, College of
Medicine, University of Florida, Gainesville, FL, USA
| | - Ryan P Theis
- Department of Health Outcomes and Biomedical Informatics, College of
Medicine, University of Florida, Gainesville, FL, USA
| | - Jesse Dallery
- Department of Psychology, University of Florida, Gainesville, FL, USA
| | | | - Merry-Jennifer Markham
- Division of Hematology/Oncology, Department of Medicine, College of
Medicine, University of Florida, Gainesville, FL, USA
| | - Stephanie A Staras
- Department of Health Outcomes and Biomedical Informatics, College of
Medicine, University of Florida, Gainesville, FL, USA
| | - Chengguo Xing
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Elizabeth A Shenkman
- Department of Health Outcomes and Biomedical Informatics, College of
Medicine, University of Florida, Gainesville, FL, USA
| | - Graham W Warren
- Department of Cell and Molecular Pharmacology and Department of
Radiation Oncology, Medical University of South
Carolina, Charleston, SC, USA
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, College of
Medicine, University of Florida, Gainesville, FL, USA
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